Failure to Follow Ordered Pressure Ulcer Treatments for Two Residents
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered for two residents with pressure injuries. For one resident with paraplegia and chronic pressure-related wounds, an in-house wound NP documented an unstageable left ischial wound measuring 20 cm x 16 cm x 1 cm with specific orders to clean the wound, apply calcium alginate with Santyl to the wound base, and secure with a bordered dressing three times per day. The January Treatment Administration Record (TAR) showed that from the beginning of the month through multiple days, Santyl was applied only once daily to a left buttock wound and the left ischium was treated once per day with Santyl and calcium alginate, rather than three times per day as ordered. A subsequent wound clinic note documented two wounds (left buttock and sacrum) with new treatment orders for each, but the TAR continued to reflect the prior regimen and did not show that the wound clinic’s specific dressing orders were implemented. Later NP documentation again referenced only a sacral wound with the same measurements as the earlier ischial wound, and an LPN clarified that the measured area included the left buttock, indicating inconsistency between documentation and ordered treatments. For another resident with a chronic stage 4 sacral pressure injury and osteomyelitis of the coccyx, a wound clinic note ordered cleansing with baby soap and water, followed by application of Endoform AM and coverage with a bordered superabsorber dressing, with dressing changes every other day. Manufacturer information described Endoform AM as an antimicrobial dressing for acute and chronic wounds that can remain in place for several days and is to be changed per physician order. However, the January TAR showed that throughout the month the resident’s sacral wound was treated instead with collagen with silver placed in the wound bed three times weekly, along with daily Vashe-soaked gauze and bordered gauze, with collagen applied first and Vashe gauze over it. The TAR did not reflect implementation of the wound clinic’s Endoform AM orders. In interviews, the ADON and DON confirmed that wound care orders from either the in-house wound NP or the wound clinic were to be followed as written and placed on the TAR, and the Administrator acknowledged that staff had missed changing the wound treatments as ordered, contrary to the facility’s wound care policy requiring wound care to be done as ordered by the physician.
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