Failure to Follow Wound Care and Preoperative Physician Orders
Penalty
Summary
Facility staff failed to follow consultant physician orders for two residents, resulting in missed and incorrect treatments. For one resident who returned from the hospital and was seen by a wound physician, the wound doctor identified a non-pressure sacral wound and ordered daily application of silver sulfadiazine and calcium alginate dressings starting on 1/28/26, with reaffirmed orders on 2/3/26 and 2/10/26. Review of the resident’s January 2026 medication and treatment records showed that these ordered sacral wound treatments were not initiated until 2/18/26, resulting in a 21-day delay in implementing the prescribed wound care. The DON confirmed that staff did not provide the ordered sacral wound treatments during this period. For another resident admitted from the hospital and scheduled for an outpatient vascular procedure on 12/12/25, the vascular physician’s office sent preoperative instructions specifying that the resident should have nothing by mouth after midnight before the procedure, that Eliquis should be stopped two days prior, and that Aspirin, Metoprolol, Vimpat, and Gabapentin could be taken the morning of surgery with a small sip of water. The medical record showed the resident was given food and fluids after midnight on the day of the scheduled procedure. The December 2025 MAR further showed staff did not stop Eliquis two days prior and did not administer the allowed morning medications (Aspirin, Metoprolol, Vimpat, and Gabapentin) on the day of the procedure. The resident’s outpatient vascular procedure was subsequently rescheduled, and the DON confirmed staff failed to follow the preoperative instructions.
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