Failure to Provide Consistent Pressure Ulcer Care and Weekly Assessment
Penalty
Summary
The facility failed to assess and document pressure ulcer characteristics and measurements on a weekly basis and did not ensure that wound care orders provided by the wound nurse practitioner were followed for one resident. The resident was admitted with multiple diagnoses, including stage 2 and stage 3 pressure ulcers, and required substantial assistance with activities of daily living. Interviews with staff confirmed that wound treatments were performed by nurses on duty, but there were inconsistencies between the treatments ordered by the wound nurse practitioner and those actually administered, as documented in the treatment administration record (TAR). The wound nurse practitioner specified that Hydrofera should be used for both the sacrum and right heel wounds, but the TAR and order summary indicated that Santyl and Xeroform were still being used for these wounds during the same period. The nurse practitioner emphasized the importance of following current wound care orders to promote healing and prevent complications. Additionally, the nurse practitioner noted that wound assessments and documentation were missing for several weeks, which is necessary to monitor wound progress and determine if treatment changes are needed. The facility's own policies required weekly documentation of wound characteristics, measurements, and pain, as well as adherence to physician orders for wound care. However, the facility was unable to provide weekly wound assessment documentation for several specified dates, and the orders from the wound nurse practitioner were not consistently implemented as directed. This resulted in a failure to provide appropriate pressure ulcer care and to prevent the development or worsening of pressure ulcers for the resident involved.