Failure to Complete Ordered Pressure Ulcer Treatments and Interventions
Penalty
Summary
The facility failed to carry out ordered interventions and treatments for a resident with pressure ulcers. Clinical record review showed that the resident, who had a history of humerus fracture, falls, and diabetes, was at risk for pressure ulcers and developed deep purple, boggy blisters on both heels, later assessed as suspected deep tissue injuries. The Treatment Administration Records (TARs) indicated multiple instances where required wound care treatments, such as application of skin prep, Santyl ointment, and dressings, were not documented as completed on several dates. Additionally, an order for Physical Therapy for positioning related to heel wounds was not documented as carried out. Staff interviews confirmed that due to staffing issues, some dressing changes and treatments were not completed as ordered, with some shifts failing to follow up on missed treatments. Nursing staff acknowledged that there were times when wound care was not performed as scheduled, and the DON stated that staff are expected to carry out treatments and therapy orders in a timely manner. The lack of documentation and completion of ordered treatments and interventions led to the deficiency in pressure ulcer care for the resident.