F0686

D

Failure to Follow Physician Orders and Aseptic Technique for Wound and Incontinence Care

Oregon, Ohio Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered pressure ulcer care, moisture-associated skin damage (MASD) care, and timely incontinence care and repositioning for residents at high risk for skin breakdown. One resident with dementia, a persistent vegetative state, total dependence for ADLs, incontinence, and tube feeding was assessed as high risk for pressure ulcer development with a Braden score of 11. After readmission from the hospital, this resident had a stage II coccyx pressure injury and excoriation/MASD to the groin and thighs, with physician and wound specialist orders for cleansing with wound cleanser or normal saline, application of zinc barrier cream to the wound bed and buttocks, coverage with a dry or foam dressing, and dressing changes every shift and as needed. The plan of care also included barrier cream after incontinence episodes, routine skin inspection, and use of a pressure-reducing mattress.

On the observed day, CNAs provided incontinence care and repositioned this resident onto his back at 7:45 A.M. Continued observation from 8:00 A.M. to 11:13 A.M. showed the resident remained on his back without further checks for incontinence care or repositioning, despite staff later stating the resident was to be checked, changed, and repositioned every two hours. At 11:13 A.M., an LPN entered the room, exposed the G-tube site, and found the resident heavily soiled with urine in an adult brief but did not address the incontinence care needs while completing G-tube and tube feeding care. At 11:58 A.M., two CNAs removed the brief and again found the resident heavily soiled with urine; they cleansed the resident with disposable wipes and incontinence spray cleanser and noted MASD and a sacral wound, but no dressing was applied to these wounds at that time, despite a current physician order for a dressing. The LPN later verified that a physician order for a dressing to the MASD and sacral wound was in place and that no dressing was present.

A second resident with paraplegia, chronic osteomyelitis, stage IV pressure ulcers to the right buttock and sacral region, incontinence, and dependence for ADLs also experienced deficient wound care. This resident had an order for an open area on the right posterior thigh to be cleansed with liquid antibacterial soap and water, patted dry, and treated with Prisma and a silicone border Zetuvit dressing once daily and as needed. During observation of wound care, an LPN gathered supplies, donned gloves and a gown, and exposed the right posterior gluteal fold wound, where the dressing was dislodged. The LPN removed the soiled dressing and packing, then, without changing soiled gloves, opened gauze packaging, cleansed the wound with wound cleanser spray instead of the ordered liquid antibacterial soap and water, and patted the wound dry with gauze. The LPN then opened and applied a collagen purcol pad instead of the ordered Prisma, and covered the wound with a silicone border dressing, all while continuing to use the same soiled gloves. The LPN confirmed that gloves were not changed between handling soiled dressings and clean supplies and that the products used did not match the physician’s orders. The DON verified that the wound treatment was not administered as ordered by the physician.