Failure to Provide Required Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the formation and progression of a pressure ulcer for one resident with an unstageable pressure ulcer. Specifically, the facility did not complete a required weekly measurement and assessment of the resident's wound during one week, as confirmed by both the treatment nurse and the Director of Nursing. The absence of this weekly skin report meant that the licensed nurses and physician did not have updated information on the wound's status, which is essential for monitoring healing or deterioration. Additionally, the facility did not administer the prescribed wound treatment on one day, as evidenced by a blank entry in the Treatment Administration Record. The resident's care plan and physician's orders required daily wound care, including cleansing and application of Thera-Honey gel with a silicone border dressing. The facility's own policy also mandated weekly wound measurements and daily monitoring. These lapses in care were confirmed through interviews and record reviews, indicating a failure to follow both physician orders and facility policy for pressure ulcer management.