Failure to Document and Administer Pressure Ulcer Treatments as Ordered
Penalty
Summary
A resident with paraplegia, bilateral below-knee amputations, and a history of pressure ulcers was admitted with two pressure ulcers and was identified as being at risk for impaired skin integrity. The resident's care plan and wound consultant report documented the presence of a Stage 3 pressure ulcer on the left proximal thigh, with specific physician orders for wound care, including cleansing with normal saline, application of gentamycin and silver alginate, and covering with a silicone bordered foam dressing to be performed daily and as needed. Review of the Treatment Administration Record (TAR) revealed that the prescribed wound care treatments were not documented as completed on multiple dates. Interviews with the DON confirmed that treatments should be documented in the TAR and that nurses are expected to enter orders promptly, provide treatments as ordered, and document them when completed. Facility policies require accurate and timely documentation of all treatments administered, but this was not done for the resident's pressure ulcer care on the specified dates.