Failure to Update and Implement Revised Wound Care Orders
Penalty
Summary
The facility failed to ensure that a physician’s updated wound care order was implemented and reflected in the resident’s active treatment orders. A progress note completed by the wound physician on 12/4/25 documented that the resident’s right shin vascular wound (Wound #2) was not healed and included a specific treatment order: cleanse the wound with normal saline, pat dry, and apply Dakin’s flush with betadine to the eschar every day and as needed. However, the resident’s Order Summary Report continued to show an earlier treatment order for a venous wound to the right lower leg, directing staff to cleanse with wound cleanser, pat dry, apply betadine-soaked gauze to the wound bed, cover with a dry dressing, and wrap with kerlex every day or as needed. During an interview and concurrent record review with the ADON, the facility was unable to provide evidence that the 12/4/25 wound care order had been implemented or that the treatment order had been updated in the clinical record. The ADON acknowledged that the treatment order for the venous wound to the right lower leg was not updated with the new order and stated that it should have been. The facility’s own Medication Orders policy required that a current list of orders be maintained in each resident’s clinical record and that treatment orders specify the treatment, frequency, and duration, but this was not followed for this resident’s wound care. The report stated that this failure resulted in the physician’s order being incorrect and created the potential for the resident’s wound to worsen.
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