Failure to Follow Physician Orders for Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for wound treatment for a resident with quadriplegia, a history of vertebral fracture, and chronic pain. The resident had a stage 3 pressure ulcer and an unstageable deep tissue injury, both not present on admission. The care plan required monitoring, documentation, and specific wound care interventions, including weekly measurements and reporting abnormalities. Physician orders specified the type of dressing and frequency for each wound site. During an observation, it was found that a nurse applied a petroleum gauze dressing to the resident's right ankle, which was not in accordance with any current physician order. The correct treatment for the right ankle, which had previously resolved, was not in place, and the nurse had mistakenly applied the dressing intended for a different wound site. The Wound Treatment Nurse was unaware that the right ankle wound had reopened and had not been notified by the nurse who performed the dressing change. The nurse who applied the dressing admitted to putting the wrong dressing on the wrong area, believing there was an order for the right ankle. The Director of Nursing confirmed that staff are expected to notify the physician and Wound Treatment Nurse of new wounds and to follow prescribed orders. The Wound Physician also stated that new wounds should be reported so appropriate treatment can be implemented. The lack of communication and failure to follow physician orders led to improper wound care for the resident.