Failure to Provide and Document Pressure Ulcer Treatment and Prevention
Penalty
Summary
The facility failed to ensure that residents received proper treatment for existing pressure ulcers and necessary services to prevent new ulcers from developing. For two residents with pressure ulcers, required wound care treatments were not documented as completed according to physician orders. Specifically, one resident with a sacral wound had missing documentation for wound care on two occasions, with no evidence in the clinical record that the treatment was performed as required. Another resident with a sacral wound also had missing documentation for daily wound care on two separate shifts, and the clinical record did not confirm that the treatments were completed. Additionally, the facility did not provide necessary preventive measures for a resident identified as high risk for pressure injury. This resident had physician orders and a care plan specifying the use of bilateral Prevalon boots while in bed to prevent pressure ulcers due to impaired mobility. However, during two separate observations, the resident was found lying in bed without the prescribed boots on, and staff confirmed that the resident was not receiving the required preventive intervention as ordered. Interviews with nursing staff, including the Director of Nursing, confirmed that the facility did not ensure proper treatment for pressure ulcers and failed to implement necessary preventive services for residents at risk. These deficiencies were identified through review of facility policies, clinical records, direct observations, and staff interviews.