Failure to Follow Wound Care Orders and Delay in Implementing New Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care according to physician orders and acceptable standards of practice for a resident with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease. The resident had a physician order directing staff to cleanse the left heel with wound cleanser, apply normal-saline–moistened gauze, and cover with a dry dressing every shift. During an observation of wound care, an RN removed the soiled dressing, cleansed the wound with wound cleanser and gauze, patted the wound dry, applied skin prep, and applied a clean dry dressing, but did not apply the ordered normal-saline–moistened gauze. The RN later confirmed she performed the wrong treatment, and the ADON confirmed the wound care provided was not consistent with the physician’s order. The deficiency also includes a lapse in implementing new wound treatment orders after discontinuation of a wound vac on the resident’s left heel. The care plan documented the resident was at risk for skin impairment and pressure ulcers, and a physician order directed discontinuation of the wound vac and application of wet-to-dry dressing until further orders were received. A Nursing Progress Note documented discontinuation of prior wound care orders, including those related to the wound vac and associated procedures, but did not document that a new wound treatment was implemented at that time. The Treatment Administration Record showed that a new wound care order for the left heel—cleanse with wound cleanser, apply normal-saline–moistened gauze, and cover with a dry dressing every shift—was not implemented until four days after the wound vac was discontinued. The ADON stated the facility had difficulty communicating with the hospice agency to clarify the wound care order and acknowledged he did not think to obtain a temporary order from the facility’s medical director.
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