Failure to Complete Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that ordered treatments for pressure ulcers were completed as prescribed for one resident with multiple wounds related to peripheral vascular disease and gangrene. Upon admission, the resident had an unstageable pressure ulcer on the right heel and a stage IV pressure ulcer on the right medial posterior knee, with specific treatment orders documented by a Nurse Practitioner/Certified Wound Specialist. However, review of the Treatment Administration Record (TAR) revealed that from the beginning of June through June 23, only a generic wound care treatment was documented as completed, rather than the specific treatments ordered. The correct treatment orders were not implemented until June 26, and there was no evidence that any wound care was provided on June 24 and June 25. Weekly wound assessments and treatments were performed by the NP/CWS, but facility staff did not follow the prescribed orders on other days. The Director of Nursing confirmed that the facility's documentation did not reflect completion of the ordered treatments except when the NP/CWS was present. The Unit Manager was unable to provide an explanation for why the ordered treatments were not completed by staff. This failure to follow the care plan and physician orders for pressure ulcer management was identified through record review, interviews, and review of facility policy.