Failure to Complete Physician-Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered by the physician for a resident with significant medical conditions, including paraplegia, diabetes mellitus, and two stage four pressure ulcers on the sacrum and right ischium. Record review and interviews revealed that there were multiple instances where prescribed wound care treatments were not administered as scheduled. Specifically, the resident and a family member reported missed treatments on several days, including a missed evening shift treatment that was only completed after being reported to the night shift nurse. Review of the Treatment Administration Record (TAR) showed several missed applications of wound care products such as zinc oxide, collagen, hydroferablue, betamethasone valerate, calcium alginate, and BNZ cream, with specific dates and times documented where treatments were not completed as ordered. The care plan for the resident indicated that pressure ulcer treatments were to be completed as ordered, and physician's orders detailed specific wound care regimens for both the sacrum and right ischium. Despite these orders, the TAR documented multiple missed treatments across different shifts and dates. The facility's own pressure ulcer and wound care policies required that physician's orders for wound care be followed, but these were not adhered to in this case. The Director of Nursing was informed of the missed treatments, but no additional information was provided at the time of the survey.