F0684

D

Failure to Follow Physician Orders for Fall Precautions and Wound Care

Washington, District Of Columbia Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

Facility staff failed to follow physician orders and the care plan for a resident with a history of falls and multiple medical conditions, including difficulty walking, muscle weakness, severe anemia, and fibromyalgia. The resident’s care plan, dated 02/04/25, identified a fall with a resulting open area on the right forehead and required floor mats on both sides of the bed when the resident was in bed to minimize fall-related injuries. Physician orders dated 02/07/25 and 02/09/25 further specified fall precautions every shift, including keeping the bed in the lowest position and placing floor mats on both sides of the bed every shift. Despite these orders and documentation that floor mats were in place on 02/09/25, an observation on 01/29/26 at 10:15 AM found the resident in bed with no floor mats on either side. During subsequent interviews, the CNA, RN, and Unit Manager each indicated they were unaware of or unsure about the floor mat requirement, and the DON later confirmed that the orders and care plan required floor mats on both sides of the bed.

Facility staff also failed to follow physician orders for wound care for another resident with a history of pressure ulcers and dysphagia, who was severely cognitively impaired, dependent for ADLs, and had one Stage 4 pressure ulcer and one unstageable pressure ulcer. Physician orders directed that the right heel wound be cleansed with wound cleanser, patted dry, treated with betadine, and left open to air twice daily, and that the sacrogluteal wound be cleansed with wound cleanser, patted dry, and treated with collagen, calcium alginate, and zinc oxide paste to the periwound, then covered with a silicone-bordered superabsorbent dressing. A wound assessment documented an unstageable right heel pressure ulcer with 100% eschar and a Stage 4 sacrogluteal pressure ulcer. However, during an observation of wound care, the LPN/Wound Nurse used normal saline instead of wound cleanser on both the right heel and sacrogluteal wounds and did not apply zinc oxide to the periwound of the sacrogluteal wound, although zinc oxide was applied to the buttocks. The LPN/Wound Nurse stated wound cleanser was not available, while the DON later stated that wound cleanser was available and that zinc oxide should have been applied to the sacrogluteal periwound as ordered.