Failure to Provide Consistent Pressure Ulcer Treatment and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a pressure ulcer. The resident was admitted with pressure ulcers on both heels and had a diagnosis of metabolic encephalopathy and muscle weakness. The care plan developed addressed only the risk of developing skin integrity issues but did not include specific goals or interventions for the resident's existing pressure ulcer. Physician orders were in place for wound care, including cleansing and dressing changes, but the care plan did not reflect the actual presence of a pressure ulcer. Documentation review revealed multiple dates where wound treatments were not completed as ordered, with no documentation of refusals or reasons for missed treatments. Progress notes did not provide explanations for the lack of completed dressing changes. During interviews, facility leadership confirmed that necessary treatment and services were not consistently provided for the resident's pressure ulcer.