Failure to Assess, Document, and Follow Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to timely and adequately assess the skin of a resident at very high risk for pressure ulcers. Despite physician orders for preventative skin care and weekly skin checks, documentation revealed that when an open area was discovered on the resident's right hip by family, staff did not measure or describe the wound as required by facility policy. Subsequent documentation and observation confirmed the presence of a facility-acquired unstageable pressure ulcer, but initial assessments lacked necessary details such as measurements, staging, and wound description. Additionally, the facility did not follow physician orders for wound care for another resident admitted with multiple pressure ulcers. Wound care orders for cleansing and dressing changes were not transcribed onto the Treatment Administration Records (TAR) for several periods, and there was no evidence that the prescribed treatments were completed. Documentation was also missing for specific dates, and staff used wound cleanser instead of normal saline on a wound, contrary to the physician's order. Interviews with nursing staff and the Director of Nursing confirmed these lapses in assessment, documentation, and adherence to physician orders. Facility policies required full assessment and documentation of pressure ulcers and completion of wound treatments as ordered, but these protocols were not followed for the affected residents.