Failure to Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
A deficiency occurred when the facility failed to provide pressure ulcer treatments as ordered for a resident with a stage 4 pressure ulcer on the left heel. The resident, who had multiple diagnoses including cellulitis, diabetes with neuropathy, and sepsis, was dependent on staff for most activities of daily living. The care plan and physician orders required wound care treatments three times per week, including cleansing, application of methylene blue, and appropriate dressings, as well as the use of pressure-reducing devices such as an air mattress, pillows to float heels, and a podus boot. Despite these orders, documentation revealed that the resident did not receive the prescribed wound care treatments on three specific dates. The Treatment Administration Record (TAR) for April and May showed missed treatments on two consecutive scheduled days and one additional day. Weekly wound assessments indicated the presence of a stage 4 ulcer with slough, granulation tissue, and moderate exudate, but no signs of infection or pain were noted. The wound physician confirmed that the wound had not declined after the missed treatments and that there was no infection present. Interviews with facility staff, including the Administrator and Director of Operations, confirmed that the expectation was for nurses to follow physician orders and that wound treatments due each day were visible in the electronic medical record system. The treatment nurse was responsible for executing orders, and oversight was provided by the DON and other managers. The facility had regular meetings to discuss wound care, but the missed treatments were not addressed prior to the survey. The facility's checklist for treatment dressing changes referenced verifying orders from the TAR and chart.