Failure to Maintain Physician-Ordered Pressure Ulcer Dressing
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including cerebral palsy, chronic obstructive pulmonary disease, polyneuropathy, obesity, osteoarthritis, seizures, peripheral vascular disease, and heart failure, did not have a physician-ordered pressure ulcer dressing in place. The resident had a stage III pressure ulcer on the sacrum, with specific orders for wound care to be performed three times a week and as needed. Documentation indicated that the dressing change was signed off as completed, but during an observation by surveyors, no dressing was found on the resident's pressure wound, nor was it present in the brief. Certified Nursing Assistants confirmed that no dressing was in place during the provision of incontinent care. The resident's care plan and facility policy required adherence to physician orders for wound care and communication of interventions to all relevant staff. The resident was dependent on staff for activities of daily living, including repositioning and incontinence care, and was at high risk for pressure ulcers. Despite these documented needs and orders, the required dressing was not applied or maintained as ordered, resulting in a failure to provide appropriate pressure ulcer care.