Failure to Provide Ordered Pressure Ulcer Care and Accurate Documentation
Penalty
Summary
The facility failed to provide ordered dressing changes and did not accurately document the progression of pressure wounds for three out of four residents reviewed for pressure injuries. For one resident, a wound initially identified as a skin tear was later documented by the wound physician as a stage three wound after debridement, but the wound nurse was unaware of this change and continued to treat it as a skin tear. Additionally, the treatment administration record showed that a prescribed dressing change was not completed on a specific date. Another resident was admitted with a right heel pressure wound and had physician orders for daily wound care, but the treatment administration record indicated that dressing changes were not completed on three consecutive days. A third resident had physician orders for twice-daily dressing changes to a left hip wound, but the treatment administration record documented that the evening dressing change was not completed on multiple dates. The wound nurse confirmed that if a dressing change was not documented, it was not performed.