Failure to Provide Prescribed Wound Care for Stage IV Pressure Ulcer
Penalty
Summary
A deficiency occurred when a nurse failed to provide prescribed wound care to a resident with a Stage IV sacral pressure ulcer on the evening of 05/07/2025. The resident, who was dependent for transfers and had intact cognition, had physician orders for wound cleansing and dressing changes three times daily. Review of the Treatment Administration Record showed no documentation of the 8:00 p.m. wound care on that date, and observation the following morning revealed the sacral wound dressing was soiled and had not been changed as scheduled. The nurse assigned to the resident on the evening in question confirmed during an interview that she did not complete the wound care due to being busy and forgetting, and the Director of Nursing corroborated this account after speaking with the nurse. The facility's policy required topical treatments and dressings to be applied as per physician orders, but this was not followed for the resident's Stage IV pressure ulcer. The omission was identified through record review, staff interviews, and direct observation, which confirmed that the required wound care was not provided as ordered, resulting in a lapse in necessary treatment and services for wound management.