Failure to Provide Ordered Daily Wound Care for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to follow physician's orders to provide daily wound care for a resident with unhealed pressure ulcers. Review of the resident's medical record and electronic Medication Administration Record (eMAR) showed that wound care orders, including cleaning and dressing of wounds on the left heel, left great toe, left hip, and sacrum, were not performed on multiple documented dates. There was no evidence in the progress notes that wound care was provided or refused on these dates, and no documentation was available to justify the missed care, such as holding wound care due to dialysis appointments. Interviews with the resident, nursing staff, and the Director of Nursing confirmed that the resident did not receive wound care as ordered on several days, particularly when the resident was out of the facility for dialysis. The staff acknowledged that there were no orders to hold wound care and that care should have been provided before or after dialysis. The resident's medical history included conditions such as atrial fibrillation, peripheral vascular disease, and unhealed pressure ulcers, and the Braden Scale assessment indicated a risk for skin breakdown.