Failure to Implement Hospital Discharge Wound Care Orders
Penalty
Summary
Staff failed to implement and follow hospital discharge orders for wound care and skin treatment for one resident. The resident was admitted with multiple complex diagnoses, including schizophrenia, bipolar disorder, bacteremia, syphilis, pseudomonas infection with multidrug resistance, third-degree burn of the left lower limb, and multiple psychoactive substance use disorders. Hospital discharge instructions dated 02/16/26 directed that dressings to the right hand and both legs be changed every 5–7 days with specific cleansing and application of Mepilex Ag secured with kerlix or tape, and that moisturizer be applied four times daily to the face, left hand, and healed areas on both legs. However, review of the resident’s electronic health record showed no physician orders entered for wound care or moisturizer. The baseline care plan dated 02/17/26 documented that the resident had multiple scabs and burns all over the body, but it did not include any instructions or interventions for care of these wounds and injuries. During an interview, the infection control nurse confirmed the resident had an open wound and stated she applied gauze to the right leg wound because it was sticking to the resident’s pants, indicating ad hoc care outside of formal orders. In a separate interview, the DON confirmed that the resident did not have wound care treatment orders or care plan interventions, acknowledged that the resident had arrived with wound care instructions, and stated that these instructions were not followed or implemented, which did not meet her expectations.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.