Failure to Follow Physician's Wound Care Orders
Penalty
Summary
The facility failed to follow a physician's wound care order for a resident who was admitted with unstageable pressure ulcers on both heels. According to the clinical records, the physician's order specified daily wound care, including cleansing the heels, applying Santyl at a nickel thickness, covering with alginate and abdominal dressing, and wrapping with Kling during each day shift. However, a review of the Treatment Administration Record (TAR) showed that the wound treatment was not performed on September 21, 2025. Nursing progress notes for that date indicated the treatment was not administered due to workflow. This was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the wound care was missed for both heels on that day.