Failure to Administer Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and preventative measures as ordered by the physician for two residents. Resident 19, who had mild cognitive impairment and multiple pressure ulcers upon admission, did not receive the prescribed treatments for various pressure areas on January 4, 2025, during the day shift. This was confirmed by interviews with the Registered Nurse Supervisor and the Director of Nursing, who acknowledged the lack of documented evidence that the treatments were administered or that the resident refused care. Resident 50, who also had mild cognitive impairment and was dependent on assistance for mobility, did not have a bariatric air mattress as ordered, following a move to a different floor. Additionally, the resident did not receive the prescribed treatment for pressure ulcers on the buttocks on two occasions in December 2024. The Director of Nursing confirmed the absence of the bariatric air mattress, and the Nursing Home Administrator confirmed the lack of documented evidence for the administration of the prescribed treatments.
Plan Of Correction
1. The medical record for R19 and R50 cannot be corrected. 2. The Director of Nursing or designee will audit current treatment administration record (TAR) for wounds and mattress orders on current residents for completion and accuracy. 3. The Director of Nursing or designee will re-educate all licensed professionals on the procedure for completion and documentation of wound care on the treatment administration record (TAR) and mattress orders. 4. The Director of Nursing or designee will audit 25% of wound care treatment documentation on the treatment administration record (TAR) and mattress orders. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.