Delay in Initiation of Physician-Recommended Wound Care
Penalty
Summary
The facility failed to initiate a wound care treatment as recommended for three days, contrary to professional standards of practice. A resident with multiple diagnoses, including acute respiratory failure, hypertension, lack of coordination, and anxiety disorder, was admitted with a potential for skin breakdown and had a documented skin injury involving the sacrum, right buttock, and left great toe. The care plan specified wound care per physician orders. On 7/24/25, the wound care team recommended a specific treatment regimen for a pressure ulcer, including cleansing with acetic acid, application of zinc oxide cream, medical-grade honey gel, calcium alginate, and foam dressing, to be performed daily and as needed. Despite these recommendations, the facility did not implement the new wound care orders until 7/27/25, waiting for the official report before making changes to the resident's treatment. The Director of Nursing confirmed that the facility delayed the initiation of the recommended wound care for two days, from 7/24/25 to 7/27/25, and did not consider this a delay in treatment. However, the facility's own policy required following treatment as ordered, which was not adhered to during this period.