Failure to Provide and Document Pressure Ulcer Care as Ordered
Penalty
Summary
The facility failed to ensure that a resident with multiple pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, the facility did not perform pressure ulcer treatments as ordered by the physician, with the Treatment Administration Record (TAR) showing that several wound care treatments were missed on multiple dates. The missed treatments included daily and every-other-day wound care for various sites, such as the right mid back, sacrum, hips, knees, toes, buttocks, and lower legs, as prescribed in the resident's physician orders. Additionally, the facility did not consistently measure and stage the resident's pressure ulcers according to professional standards. While an outside wound care Nurse Practitioner (NP) typically performed weekly measurements and staging, there were instances when the NP was absent, and the required assessments were not completed by a Registered Nurse (RN) as expected. Documentation was lacking for wound measurements and staging on specific dates, and staff interviews confirmed that neither the interim DON nor the Director of Clinical Operations had performed or documented these assessments during the relevant periods. The resident involved had a complex medical history, including multiple stage 3 and 4 pressure ulcers, burns, contractures, and a recent admission to hospice care. Despite the presence of detailed wound care orders, the facility's failure to carry out and document the prescribed treatments and assessments resulted in a deficiency related to the provision of pressure ulcer care and prevention.