Failure to Complete Pressure Ulcer Dressings as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer dressings were completed as ordered for a resident with multiple medical conditions, including limited mobility, obesity, and a history of falls and transient ischemic attacks. The resident was assessed as having moderately impaired cognition and was at low risk for pressure ulcer development according to the Braden scale, but required frequent repositioning and maximum assistance due to spending most of each shift in bed or a chair. Physician orders were in place for wound care, including cleansing and application of triad ointment to wounds on the buttocks and sacral area, with specific instructions for frequency and additional interventions such as use of a low-air loss mattress and regular turning. Despite these orders, review of the Treatment Administration Record (TAR) revealed that wound care treatments were not documented as completed on three separate night shifts. Staff interviews confirmed that the treatments were not applied as ordered on those dates. Observations and medical record reviews further indicated that the resident developed a deep tissue injury (DTI) on the left buttock, classified as a pressure ulcer, in addition to a moisture-associated skin damage (MASD) wound. Facility policy required adherence to physician orders and regular monitoring of wound care, but these protocols were not followed, resulting in a deficiency related to pressure ulcer care.