Failure to Implement Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide necessary treatments for two residents with pressure ulcers, as identified through clinical record reviews and staff interviews. Resident 71 had a stage 3 pressure ulcer on the left heel, and a wound consult recommended cleansing with wound cleanser, applying betadine, and leaving the wound open to air daily and as needed. However, the physician's orders and treatment administration record (TAR) showed that this order was not implemented. The Director of Nursing (DON) confirmed that the treatment order was changed during wound rounds but was not put into place. Similarly, Resident 177 had a stage 2 pressure ulcer on the sacrum, with a wound consult recommending cleaning with wound cleanser, applying house barrier cream, and leaving the wound open to air daily and as needed. Again, the physician's orders and TAR revealed that this order was not implemented. Both the DON and the Nursing Home Administrator confirmed that the order to change the treatment was not implemented. These findings indicate a failure to adhere to professional standards of practice in treating pressure ulcers, as required by regulations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1. Resident R71 and R177's wounds were reassessed, and physicians were notified that new wound orders implemented on wound rounds were not transcribed to the TAR (treatment administration record) and were not implemented. There were no unfavorable outcomes related to the facilities alleged deficient practice. 2. Audit of current residents with pressure ulcers completed to ensure that recommended treatments are in place as recommended by the wound team. 3. DON/Designee will complete training to licensed staff on the components of this regulation, including ensuring treatment orders are transcribed to the TAR in a timely manner. 4. DON/Designee will have complete audits of 5 residents with pressure wounds 2 x a week x 4 weeks, then 1 x a week x 4 weeks, then 2 x a month, then 1 x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings in QAPI. 5. Date of Compliance will be February 28, 2025.