Failure to Ensure Wound Treatment Orders and Documentation for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when the facility failed to ensure that wound treatment orders were in place for a resident with multiple medical conditions, including surgical aftercare, heart disease, respiratory failure, chronic kidney disease, and diabetes. The resident was admitted with deep tissue injuries (DTIs) to the bilateral buttocks, which were documented as dark reddish purple, hard areas. Although the care plan included the application of barrier cream after each incontinent episode, and physician orders were in place for pressure relief interventions, there was no documented evidence that protective cream was applied to the affected areas from the time of admission until several days later. Further review revealed that an order for protective cream to the bilateral buttocks was not obtained until after the resident developed Moisture Associated Skin Damage (MASD). The Treatment Administration Record did not show documentation of barrier cream application prior to this order, and the DON confirmed that there was no documentation or order for barrier cream until after MASD was identified. Facility policy required measures to maintain skin integrity and prevent pressure ulcers, but these were not consistently implemented for this resident.