Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to provide ordered wound care to a resident with unstageable pressure ulcers on the right buttock and right lateral foot. The resident, an elderly female with a history of leg fracture, dementia, and mild protein-calorie malnutrition, was identified as being at risk for pressure ulcers. Her care plan and physician orders specified daily wound care, including cleansing, application of collagen sheets, and appropriate dressings. However, on the specified date, the RN did not perform the required wound care and documented it as completed, despite admitting in an interview that the treatment was not done due to being busy and forgetting. Observations revealed that the dressing on the resident's right buttock was dated two days prior, and there was no dressing on the right lateral foot wound. The paid caregiver confirmed that the dressings had not been changed as scheduled and had not reported this to nursing staff. Interviews with the DON, ADON, and Treatment Nurse confirmed that wound care was to be performed by nurses on weekends when the Treatment Nurse was not present, and that the failure to provide wound care as ordered was not communicated to the wound care physician. The facility's policy required systematic assessment, prompt treatment, and documentation for pressure injury prevention and management. Despite these policies, the resident did not receive the necessary wound care on the specified date, and the lapse was not reported to the physician or addressed by staff at the time, resulting in a failure to meet the standard of care for pressure ulcer management.