Failure to Follow Physician’s Wound Care Orders for Heel DTI
Penalty
Summary
The facility failed to follow a wound care physician’s orders for treatment of a resident’s left heel deep tissue injury (DTI). On January 15, 2026, the resident was documented as having a right heel DTI measuring 2.5 x 3.5 cm and a left heel DTI measuring 2.5 x 2.3 cm, with an order to cleanse both heels with soap and water, apply skin prep, and leave them open to air daily; review of the January 2026 Treatment Administration Record (TAR) showed this initial skin prep order was followed. On January 22, 2026, the wound physician documented that the right heel DTI had worsened to 3.7 x 6.0 cm and the left heel DTI measured 0.3 x 0.3 cm, and issued new orders to apply Betadine-soaked gauze with a dressing to the right heel and to apply Betadine to the left heel and leave it open to air. TAR review confirmed that the right heel treatment was carried out, but the left heel Betadine treatment was not documented as provided from January 23, 2026, through February 8, 2026. In an interview on March 31, 2026, at 1:00 p.m., the DON confirmed that the left heel DTI order from the wound physician had been missed and therefore not followed, resulting in noncompliance with 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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