Failure to Administer Ordered Pressure Ulcer Care Due to Lack of Supplies
Penalty
Summary
A deficiency occurred when a resident with diagnoses including end stage renal disease, cellulitis of both lower limbs, and chronic pain did not receive pressure ulcer care as ordered by the physician. The resident's care plan required wound treatments to the left medial ankle, posterior Achilles, and bilateral heels, including the use of normal saline, iodoform, betadine, and xeroform dressings. Documentation revealed that on specific dates, wound care was not administered as ordered: the wound care was placed on hold without physician authorization, and betadine was not available for use on the resident's heels. Observations confirmed that dressings were not changed as scheduled, and betadine was not applied during wound care treatments. Further review and interviews established that the facility had run out of betadine, and the DON confirmed that the resident had not received the prescribed wound care. There was no evidence in the medical record that the physician had ordered wound care to be held. The facility's policy required identification of residents at risk for pressure injuries and provision of care for existing wounds, but these interventions were not followed for this resident, resulting in a failure to provide pressure ulcer care as ordered.