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Based on observation, clinical record review, and interview, it was determined the facility failed to provide wound care as ordered by the physician for 1 (# 5) of 9 (# 4-#13) in-patient clinical records reviewed. Failure to follow the physician order for wound care did not promote wound healing and increased the likelihood for infection and deterioration of the wound. The failed practice affected Patient #5 and had the likelihood of affecting any patient with wound care orders. The findings were:

A. Clinical record review revealed Patient #5 was admitted to the facility on 12/10/14 at 1703. Admission History and Physical included physical examination that stated "Her skin is clean, dry and intact without signs of rash, tumor or breakdown with the exception of the left foot, which has a lateral metatarsal head erosive lesion and inner digital erosion between the fourth and fifth toes. These are chronic and greater than six months, but are healing very slowly."
B. Physician order on 12/10/14 at 1819 was noted for "Wound/skin/dsg (dressing) orders, bid (twice daily). Cleanse with soap and water, cover lateral decubitus with Santyl then Telfa. Coat between toe 4-5 with Gentamycin lightly then wrap foot with gauze."
C. Review of nursing documentation of wound care revealed wound care was not documented 4 of 16 times bid as ordered on: 12/11/14 (bid); 12/12/14 (am with Santyl) and 12/13/14 (pm).
D. The failure to document wound care as ordered by the physician was confirmed on 12/19/14 at 1600 by Registered Nurse #2 and the Director of Education.