Failure to Document and Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. For two residents with pressure injuries, there were multiple instances where prescribed wound care treatments were not documented as completed on the Treatment Administration Records (TARs). Specifically, one resident with stage 3 pressure injuries to both heels had missing documentation for Betadine swabstick applications and for a regimen involving cleansing, skin prep, medical grade honey, calcium alginate, and bordered gauze. Another resident with an unstageable pressure injury to the right heel had missing documentation for wound care treatments involving cleansing, Betadine application, and dressing changes as ordered by the physician. The clinical records and wound care tracking confirmed the presence of significant pressure injuries in both residents, with relevant diagnoses including chronic pain, muscle weakness, type 2 diabetes mellitus, and edema. During an interview, the Nursing Home Administrator was unable to provide additional information regarding the missing wound care documentation and acknowledged that wound care should have been documented as completed. The findings were based on policy review, clinical record review, and staff interviews.