Failure to Provide and Document Pressure Ulcer Care as Ordered
Penalty
Summary
The facility failed to ensure that a resident received pressure ulcer care in accordance with professional standards and physician orders, as evidenced by multiple missed and undocumented wound treatments. The facility's policy requires that wound care be provided as ordered, with all treatments documented on the Treatment Administration Record (TAR) or in the electronic health record. For the resident in question, the TAR showed numerous blank entries for both sacral and bilateral ischial tuberosity wounds, indicating that wound care was not completed or not documented as completed on several occasions over a two-month period. Interviews with nursing staff, including RNs, LPNs, the Assistant Director of Nursing/Wound Nurse, and the Director of Nursing, confirmed that a blank TAR entry means the treatment was not completed, and that a specific code (the number 4) would indicate a progress note explaining why a treatment was missed. In this case, there were multiple dates with blank TAR entries and no corresponding progress notes, confirming that wound care was not provided or not documented as required. The resident had orders for specific wound care regimens, including cleansing with Vashe wound cleanser, application of skin prep, use of hydrofera blue classic and other dressings, and securing with various tapes and pads. Despite these orders, the TAR indicated that treatments to the sacrum were not documented as completed 26 times, and treatments to the bilateral ischial tuberosities were not documented as completed 11 times. This lack of documentation and completion of wound care represents a failure to provide care consistent with professional standards and the facility's own policies.