Failure to Document Completion of Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that treatment orders for pressure ulcer care were consistently signed out as completed for two residents. For one resident with a history of stroke, renal insufficiency, depression, and obesity, documentation showed that multiple treatment orders—including dressing changes, skin prep applications, ointment applications, and wound evaluations—were not signed out as completed on several dates across multiple months. The resident was identified as being at risk for pressure ulcers and had documented unhealed stage 1 pressure injuries. The care plan directed staff to administer medications and treatments as ordered, but the Treatment Administration Records (TARs) revealed repeated omissions in documentation of completed care. Another resident, who had no cognitive impairment and was at risk for pressure ulcers with three unhealed stage 4 pressure ulcers, also had multiple treatment orders not signed out as completed. These included wound evaluations, dressing changes, and specific wound care procedures for sacral and buttocks ulcers, as well as a puncture wound. The TARs for this resident showed numerous instances where required treatments and evaluations were not documented as completed over several months. Interviews with the resident indicated that dressings and treatments were performed daily, but staff interviews confirmed that if an order was not signed out on the TAR, it was considered not done. Further investigation revealed that the facility lacked a clear policy regarding the administration and documentation of treatment orders. The Assistant Director of Nursing (ADON) was unable to locate a relevant policy in the facility’s records or obtain one from the previous owners. Corporate staff were also unable to provide the requested policies by the time of the survey. This lack of policy guidance contributed to inconsistent documentation practices and the observed deficiencies in pressure ulcer care.