Failure to Provide and Document Ordered Pressure Ulcer Care
Penalty
Summary
A resident with a history of hemiplegia, aphasia, dysphagia, acute respiratory failure, and an unstageable sacral pressure ulcer was admitted to the facility and identified as high risk for pressure wounds, with a Braden Score of 12. The resident was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. The care plan included the use of a moisture barrier cream with zinc after each incontinent episode and daily wound treatments as ordered by the physician. Despite these orders, observations and record reviews revealed that wound care and dressing changes were not performed as prescribed. On observation, the resident's wound dressing was found to be dated four days prior, despite a daily dressing change order. The wound was noted to have increased in size and showed signs of infection, with cultures later confirming the presence of Proteus mirabilis and CRE. The Treatment Administration Record (TAR) showed multiple dates where the application of the moisture barrier cream was not documented as completed, indicating missed treatments. Interviews with nursing staff, the wound care director, the nurse practitioner, and the wound physician confirmed that wound care and dressing changes were not consistently performed or documented as required. Staff acknowledged that failure to provide and document these treatments could lead to wound deterioration and infection, which was observed in this case as the resident's wound worsened and became infected.