F0686

D

Failure to Follow Physician Wound Care Orders for Pressure Ulcer Treatment

Houston, Texas Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident with a pressure ulcer received wound care treatment and services as ordered by the physician and consistent with professional standards of practice. The resident was an adult female with scoliosis, type 1 diabetes mellitus with hyperglycemia, end-stage renal disease on dialysis, and legal blindness, who was admitted with a pressure ulcer as documented on the admission MDS. Her comprehensive care plan for skin concerns, dated 12/29/25 and revised 01/02/26, included an intervention to provide treatment as ordered. Physician orders dated 01/30/26 for an unstageable pressure injury to the right hip directed staff to cleanse with normal saline or house wound cleanser, pat dry, apply skin prep to the peri-wound edge, apply Santyl to the wound bed, apply calcium alginate, and cover with border gauze every shift. The MAR/TAR for February 2026 reflected that the facility was following this prescribed order.

On observation of wound care on 02/18/26 at 12:04 PM, LVN A prepared the bedside table with disinfectant wipes, performed hand hygiene, donned PPE, and set up wound supplies. LVN A removed the old dressing, changed gloves with hand hygiene between glove changes, and cleansed the right hip wound bed with wound cleanser using one wipe at a time. The wound bed was described as dry and pink with tiny black dots. After cleansing, LVN A again changed gloves and sanitized hands, but did not apply skin prep to the peri-wound edge and did not apply Santyl to the wound bed as required by the current physician order. Instead, LVN A applied calcium alginate directly to the wound bed and covered it with a border dressing. The resident tolerated the procedure without complaints of discomfort.

In interviews, the DON confirmed that, after reviewing the resident’s orders, LVN A should have followed the physician’s wound care orders to apply skin prep to the wound edges and Santyl to the wound bed. LVN A reported that earlier that day, during rounds with the Wound Specialist NP, the NP had instructed her not to apply Santyl to the right hip wound, but she acknowledged that she had not yet transcribed this new order into the system. LVN A stated that until a new order is entered, staff must follow the existing order. The DON, when asked what order a nurse would follow if a new wound care order had not been updated in the system, stated that such a situation would not occur because she or the ADON would have transcribed the new treatment. RN B stated that if a wound dressing became soiled and needed changing, she would follow the order in the system and that the Wound Care NP typically entered new orders at the time of wound rounds using a laptop cart. Facility policies on Medication Administration and Provision of Quality of Care required that medications and treatments be administered as ordered by the physician and in accordance with professional standards of practice and the resident’s care plan.