Failure to Provide and Document Pressure Ulcer Treatment as Ordered
Penalty
Summary
A review of facility policies, clinical records, and staff interviews revealed that the facility failed to provide pressure ulcer treatments as ordered by the physician for one resident. The facility's wound management policy required that wound treatments be administered according to physician orders, specifying the cleansing method, dressing type, and frequency. The resident in question was cognitively impaired, incontinent of bowel and bladder, and at risk for pressure ulcers. On assessment, the resident was found to have a fluid-filled blister on the right abdomen, with physician orders directing the application of a protective barrier every day and evening shift. The care plan also specified avoidance of tight clothing and adherence to the treatment orders. However, review of the Treatment Administration Records for the relevant month showed no documented evidence that the prescribed treatments were completed as ordered. This lack of documentation was confirmed by the Nursing Home Administrator.