Failure to Perform and Document Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were performed as ordered for a resident with multiple complex medical conditions, including paraplegia, a stage 4 sacral pressure ulcer, and third-degree burns on both lower legs. The resident was assessed as totally dependent on staff for hygiene, dressing, rolling, and transfers, and was always incontinent of bowel. Physician orders required daily wound care to the sacrum, but documentation showed that wound care was not performed on at least two specified days. During observation, the resident's wound dressings were found to be undated and uninitialed, and the resident reported that staff were not changing the dressings daily as required. Interviews with staff confirmed the importance of daily wound care and proper documentation, with the wound care nurse and DON both acknowledging that lack of documentation could mean the care was not provided. The facility's policy required individualized care plans and documentation of dressing changes on the treatment administration record or electronic health record. The failure to perform and document wound care as ordered constituted a deficiency in the facility's pressure ulcer care practices.