Failure to Implement Wound Care Recommendations for Pressure Ulcer Management
Penalty
Summary
The facility failed to implement recommendations made by the wound care service for a resident with pressure ulcers. The wound care service had recommended the addition of modular protein and a multivitamin with zinc supplements to the resident's care plan, as documented in a progress note. However, a review of the resident's orders showed that these supplements were not added, and there was no documentation explaining the omission. The DON confirmed that there was no information in the chart regarding the absence of the modular protein and noted that the facility's physician typically does not order the multivitamin with zinc and vitamin C. The resident reported having pressure ulcers that seemed to be improving but was unaware of how they developed.