Failure to Assess and Treat Pressure Ulcer per Physician Orders
Penalty
Summary
The facility failed to ensure comprehensive assessment and appropriate wound care for a resident admitted with a right heel pressure injury. Upon admission, the skin assessment identified a right heel pressure area but did not document the wound's stage, size, appearance, drainage, odor, or the condition of the surrounding skin. The admitting nurse did not perform a thorough assessment as required by facility policy, and a comprehensive evaluation was not completed until the wound physician's consult two days later, which identified the wound as an unstageable pressure ulcer with significant slough. Additionally, the facility did not follow the wound physician's updated treatment recommendations. The physician ordered daily wound care with saline, medical grade honey, and foam dressing, but the Treatment Administration Record showed that the prescribed treatment was not performed on two consecutive days. The Assistant Director of Nursing confirmed that the physician's orders were not followed, resulting in missed wound care for the resident's unstageable pressure ulcer.