Failure to Provide and Document Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with Moisture Associated Skin Damage (MASD) who was at risk for worsening skin breakdown. The resident, an older adult female with a history of psychiatric and medical conditions including schizophrenia, depression, and incontinence, was admitted and later readmitted to the facility. Her care plan identified actual and potential skin integrity impairment related to MASD and outlined interventions such as keeping the skin clean and dry, monitoring and documenting the wound, and following physician-ordered treatments. Despite these interventions, the resident did not receive all of her ordered wound care treatments. Documentation revealed that eight ordered treatments in one month and two in the following month were either missed or not documented. The Treatment Administration Record (TAR) showed multiple instances where wound care was not completed or not recorded as done. Staff interviews confirmed that the resident frequently refused care, including wound care, repositioning, and hygiene, and that these refusals were not always properly documented in the TAR or in progress notes as required by facility policy. Medical records and wound assessments indicated that the resident's wound worsened over time, with the development of a partial thickness non-pressure wound and later a Stage 3 pressure ulcer. The physician and staff noted repeated refusals of care by the resident, and the family was informed of the situation. Staff acknowledged that missed or undocumented treatments could lead to further complications. The facility's policy required complete and accurate documentation of care, but this was not consistently followed in this case.