Failure to Follow Physician Orders for Wound and Skin Treatments
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for wound and skin care for two residents. For one resident with Type 2 diabetes mellitus and unspecified dementia, a physician order dated 2/5/2026 directed that Venelex ointment be applied to the groin and buttocks every shift for a rash, and the care plan instructed staff to administer all treatments as ordered and monitor for effectiveness. On 2/9/2025 at 10:32 AM, the DON, an RN, removed the resident’s blankets and pulled back the incontinence brief, revealing a bright red right groin area, but did not apply any ointment to the groin despite the active order. When interviewed shortly afterward, the DON acknowledged that if the order specified cream to the groin, it should have been applied. The second resident had multiple diagnoses including cellulitis of the right lower limb, chronic ulcer of the right lower leg, venous insufficiency, atrial fibrillation, CHF, chronic kidney disease stage 3, pulmonary hypertension, Type 2 diabetes mellitus, and hypertension. The care plan documented cellulitis and chronic pressure ulcers of both lower legs, with interventions to administer treatments as ordered, follow facility policies for skin breakdown prevention and treatment, and have the wound doctor assess and treat as needed. Physician orders included daily cleansing and dressing of the left lower extremity with NS, xeroform, dry rolled gauze, and ace wraps; elevation of lower extremities; application of Santyl to right lower leg/foot slough every dayshift; and cleansing of the right foot with NS and wound cleanser followed by Betadine-soaked gauze between the toes. On the date of observation, the DON performed wound care for this resident in the absence of the wound nurse. The DON cleansed and dressed the left foot with xeroform, gauze, and ace wrap consistent with orders. The right lower leg and foot were observed to be very swollen, reddened, oozing serosanguinous fluid and blood, with white patches and open sores. The DON cleansed the right toes, foot, and ankle with NS, applied Betadine between the toes and on the top of the foot, and then applied xeroform to the top of the right foot before covering and wrapping it. During the procedure, the resident stated that the wound clinic had changed the treatment to Santyl and showed the DON the wound physician’s orders specifying Santyl to the right lower leg/foot. The DON responded that she would have to correct the orders but continued using xeroform. Later, the DON acknowledged that a Santyl order dated 2/2/2026 was already in the record and that the original xeroform order had not been discontinued, resulting in the continued use of xeroform instead of Santyl as ordered for the right lower leg/foot.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.