Failure to Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
A deficiency was identified when a resident with a history of diabetes mellitus and psoriasiform dermatitis was observed to have multiple pressure ulcers without the required dressings in place. During care, staff noted open areas on the left hip, lower back/sacrum, and right buttock, with the right buttock showing bloody drainage. Certified nursing assistants (CNAs) reported that they were not informed by the previous shift about missing dressings, and no dressings were found in the resident's brief or linens. The wound nurse stated that treatments had last been completed several days prior, and the physician's orders required dressings to be changed if soiled or dislodged, as well as on a scheduled basis. Record review revealed that physician's orders specified wound care regimens for the sacrum, right buttock, and left hip, including cleansing, drying, and application of hydrocolloid or foam dressings at specific intervals and as needed. Documentation showed that some scheduled treatments were not completed as ordered, and there was no record of as-needed treatments being performed when dressings were missing. The care plan indicated that wound care should be provided as ordered, but observations and interviews confirmed that the required treatments were not consistently in place, resulting in a failure to follow physician orders for pressure ulcer care.