Failure to Provide Ordered Wound Care for Chronic Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own wound care policy for a resident with multiple chronic pressure ulcers. The resident, an older female with mild cognitive impairment, paraplegia, pancreatic cancer, diabetes, and multiple stage 4 pressure ulcers (left hip, sacral, left ischium, right buttocks) and a stage 3 right heel ulcer, had wound care orders from a wound care physician. The physician ordered a specific product to be applied after cleansing the sacral and left ischium wounds, followed by a silicone super absorbent dressing, to be done daily and as needed. The facility’s policy stated that wound dressing changes are to be performed as ordered by the physician using clean technique on all chronic or contaminated wounds. On observation, CNAs providing incontinence care found the resident’s stage 4 sacral and stage 4 left ischium wounds with soiled, dirty dressings that were peeling off and dated two days prior, indicating that wound care had not been provided the previous day. Later that morning, an LPN performing wound care confirmed that the old dressings were soiled, dirty, peeling, and dated two days earlier, and stated that this indicated no wound care had been done the day before. During the dressing change, the LPN cleansed the wounds with saline, patted them dry, and applied medi honey and calcium alginate instead of the ordered product and silicone super absorbent dressing, explaining that the ordered product could not be found in the treatment cart. The wound care physician later stated that the ordered product was intended to debride dead tissue from the wound bed and that the facility should have used it as ordered.
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