Failure to Consistently Complete Pressure Ulcer Treatments as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of a stage 3 pressure ulcer on the left heel, chronic venous hypertension with ulcers, myocardial infarction, and type 2 diabetes mellitus did not consistently receive pressure ulcer treatments as ordered by the physician. The treatment orders specified daily wound care, including cleansing with normal saline, application of skin prep and Medihoney, and dressing with ABD pad, Kerlix gauze, and ACE wrap. Review of the Treatment Administration Records (TAR) for February and March revealed multiple dates where the dressing change was not signed off as completed, indicating the treatments were not performed as ordered. Interviews with nursing staff confirmed awareness that dressing changes were sometimes missed, with staff citing staffing challenges as a contributing factor. The Director of Nursing acknowledged that unsigned treatments on the TAR indicated they were not completed and was only able to confirm completion for one of the missed dates. Facility policy required adherence to physician orders for pressure ulcer care, but this was not consistently followed, resulting in the deficiency.