Failure to Provide and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
A resident was admitted to the facility with multiple complex medical conditions, including a stage 4 pressure ulcer on the sacral region and deep tissue damage to the left heel. Physician orders were in place for daily wound care treatments for both pressure ulcers, specifying cleansing, application of topical agents, and dressing changes. However, a review of the Treatment Administration Record (TAR) revealed missing documentation for the prescribed treatments on two consecutive days for both wounds. The Director of Nursing confirmed that blank entries on the TAR indicated the treatments were not performed, and acknowledged that the treatments should have been initiated as ordered, even though the resident was a new admission and it was the weekend. The facility's policy required full assessment and documentation of pressure ulcers, including current treatments, which was not reflected in the records for the days in question. The failure to provide and document the ordered wound care treatments constituted a lapse in ensuring that services met professional standards of quality for the resident's pressure ulcers.