Failure to Provide Timely and Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards and facility policy. The resident was admitted with multiple pressure ulcers, including a Stage 4 ulcer and unstageable ulcers, and had physician orders for negative pressure wound therapy to be applied every 72 hours. However, documentation did not show that this therapy was administered as ordered on two specific dates. Additionally, the Treatment Administration Record did not reflect that the negative pressure wound therapy was consistently provided according to the physician's instructions. Further review revealed that a complete wound evaluation for one of the resident's pressure ulcers was not performed upon admission, nor were weekly wound assessments consistently documented as required by the facility's policy and the resident's care plan. The first complete evaluation for the left ischial ulcer was not documented until two weeks after admission, and there was no evidence of weekly wound evaluations during a specified week. The Director of Nursing confirmed that these assessments should have been completed and could not provide evidence that they were done as required.