Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to meet professional standards of practice by not following a physician's order for wound care for one resident. The resident was admitted with a diagnosis of a left fibula fracture, specifically an open fracture type 1 or 2, and was progressing with routine healing. A physician's order dated 12/03/25 directed staff to remove the resident's sutures and staples from the left leg. However, staff did not carry out this order as required. Instead, the removal of the sutures and staples was delayed until the resident attended an outside wound care clinic, where the procedure was performed on 12/23/25. The Director of Nursing confirmed during an interview that staff were expected to follow physician's orders and acknowledged that the removal had not been completed by facility staff as ordered. This lapse was identified through record review and staff interview.