Failure to Provide Consistent Pressure Ulcer Care and Missed Wound Treatments
Penalty
Summary
The facility failed to ensure a comprehensive wound management program for a resident with a Stage 4 pressure ulcer. The resident, who had multiple comorbidities including severe cognitive impairment, diabetes, and immobility, was identified as high risk for pressure ulcers. The care plan included interventions such as a pressure-relieving mattress, repositioning every two hours, use of barrier cream, nutritional supplements, daily skin assessments, and physician-ordered wound treatments. Despite these interventions, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed multiple missed wound treatments over several months, with no documented explanations for the missed administrations. These missed treatments included cleansing, packing, and application of various dressings, all of which were ordered to be performed daily or by shift. Interviews with nursing staff, the ADON, and the wound care provider confirmed that the wound progressed from moisture-associated skin damage to an unstageable wound and then to Stage 4, with the wound peaking in size before showing improvement. The Director of Nursing verified that there was no documentation to support that wound treatments were provided as ordered on the identified dates. Facility policy required adherence to physician-ordered wound treatments, but this was not consistently followed, as evidenced by the lack of documentation and missed treatments.