Failure to Implement and Follow Wound Care Orders for Stage 4 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to follow and timely implement wound care treatment orders for a cognitively intact resident with a Stage 4 sacral pressure ulcer that was present on admission. The resident had multiple wound NP notes documenting specific treatment orders, including cleansing with Dakin’s solution, application of collagen or collagen with silver, calcium alginate, skin prep to the periwound, and use of a wound vac with specified frequency. On one occasion, a new daily treatment order dated 09/17/2025 was not initiated until 09/23/2025, as shown on the September ETAR. On another occasion, a new order dated 10/22/2025 to cleanse with Dakin’s solution, apply collagen particles, and apply continuous wound vac therapy three times per week was not fully transcribed; the ETAR only reflected changing the wound vac dressing every three days and lacked instructions to cleanse with Dakin’s or apply collagen particles. Further, a subsequent NP order dated 10/29/2025 to cleanse with Dakin’s solution, apply collagen particles, and apply continuous wound vac therapy on Wednesdays and Saturdays was not reflected as a changed order on the October ETAR. A later NP order dated 12/10/2025 for daily cleansing with Dakin’s solution, application of skin prep to the periwound, collagen with silver, calcium alginate, and a silicone bordered superabsorbent dressing was not initiated until 12/19/2025, and the December ETAR lacked documentation that treatments were completed on multiple specific dates. Interviews with an LPN and the ADON confirmed that wound treatments were to be documented in the ETAR and that blanks indicated treatments were not completed, and that the ADON transcribed NP orders after receiving a report one to two days after NP visits. Facility policies required that all physician orders be implemented as received and that residents with pressure ulcers receive necessary treatment and services consistent with professional standards of practice.
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