Failure to Follow and Document Physician-Ordered Wound Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide wound treatment and care according to physician orders for residents with non-pressure related skin conditions. Resident B, who had diagnoses including diabetes, atrial fibrillation, hypertension, and GERD, was cognitively intact and admitted with a surgical wound to the scrotal and perineal area. A care plan dated 2/5/26 identified an alteration in skin integrity and directed staff to provide treatments as ordered and monitor for infection. A physician’s order dated 2/5/26 specified application of a NPWT (wound vac) dressing with white foam to the scrotal/perineal area, to be changed every 48–72 hours. The TAR did not show the wound order signed out for 2/5/26. The DON reported that the resident arrived from the hospital with a wet-to-dry dressing after the hospital had removed the wound vac, and that she removed this dressing and attempted multiple times to apply the wound vac without success. She stated she did not obtain a new physician order when the wound vac could not be applied and instead packed the wound with wet-to-dry gauze and placed an adaptic dressing over it, deviating from the existing order. The deficiency also includes failure to follow and accurately document wound treatment orders for Resident C, who had diagnoses including a non-pressure ulcer of the left foot, heart failure, anemia, and restless leg syndrome, and was documented as alert and oriented with normal cognitive status. A care plan dated 3/10/26 identified alteration in skin integrity to the left foot with approaches to complete treatments as ordered and observe for infection. A physician’s order dated 3/11/26, to begin 3/12/26, directed that the left plantar foot wound be treated with iodoform packing strip to the wound bed, betadine-soaked gauze, a dry 4x4, kerlix wrap, and an ace bandage. The TAR indicated this ordered treatment was signed out as completed on 3/12/26. However, during an observed wound treatment on 3/13/26, an RN removed a foam dressing dated 3/12/26 and stated that it was the wrong dressing on the wound, indicating that the treatment documented as completed on the TAR did not match the physician’s ordered regimen. The DON acknowledged understanding of the concern regarding the wound treatment and the signed-out treatment that was not followed.
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