Failure to Provide Prescribed Wound Care for Pressure Ulcers
Penalty
Summary
A resident with multiple complex medical diagnoses, including bacteremia, morbid obesity, chronic kidney disease, and chronic respiratory failure, was readmitted to the facility with several unhealed pressure ulcers. Upon readmission, the resident had documented wounds to the left buttocks, bilateral buttocks, left hip, and sacral area, as well as other sites. Despite these documented wounds, there were no corresponding treatment orders for these areas on the resident's Physician Order Sheet (POS) at the time of readmission. Interviews with nursing staff, including the wound care nurse, LPN, and wound care coordinator, revealed that it was the responsibility of the admitting nurse or wound care nurse to ensure that hospital treatment orders were entered and that wound care began upon admission. However, the review of the Treatment Administration Record (TAR) and POS showed missing treatment orders and missing signatures for wound care treatments, indicating that prescribed wound care was not performed for certain wounds. Staff members acknowledged that if treatment orders are not present or not signed out, it is assumed that the treatment was not performed, which could result in wounds worsening or becoming infected. Documentation from the resident's care plan and hospital records confirmed the presence of pressure ulcers and the need for ongoing wound care. Despite this, the facility failed to ensure that necessary wound care orders were entered and that treatments were administered as prescribed. The absence of a wound care coordinator at the time further contributed to the lack of oversight and follow-through on wound care orders, as confirmed by staff interviews and review of facility policies and job descriptions.