Failure to Provide Pressure Injury Treatment as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including COPD, chronic respiratory failure with hypoxia, Alzheimer's disease, and generalized muscle weakness, did not receive pressure injury treatment as ordered by the physician. The resident was observed with denuded skin and a stage 2 pressure injury on the sacral/coccyx and buttocks area, with no dressing in place. The physician's order required daily application of zinc oxide ointment and coverage with a foam dressing, to be applied every night shift and as needed after cleansing with normal saline. On the morning in question, the resident was found without the required foam dressing, and only zinc oxide ointment was applied by the nurse on duty. The nurse was unaware of the as-needed order for the foam dressing and did not reapply it during her shift, believing it was only to be applied at night. The CNA who assisted the resident in the morning did not inform the nurse that the dressing was missing. The night shift nurse had applied the foam dressing earlier, but was not notified that it had been removed or soiled. The Director of Nursing confirmed that all pressure injury treatments should be administered as ordered, and that the foam dressing was important for the resident's wound protection, especially since the resident often sat in a chair and refused to use a gel cushion.