Failure to Consistently Document and Administer Ordered Pressure Ulcer Treatment
Penalty
Summary
A resident with diagnoses including hypokalemia and hyperlipidemia developed incontinence associated dermatitis (IAD) on the sacrum, which was later identified as an unstageable pressure ulcer. The wound clinic provided a treatment plan that included daily cleansing with soap and water, patting dry, and applying medical grade honey, calcium alginate, and bordered gauze. A physician's order for this treatment was documented in the Medication Administration Record (MAR) with specific instructions for daily and as-needed application. Review of the resident's MAR revealed that the required wound care treatment was not documented as completed on two separate dates, as the corresponding boxes were left blank. During an interview, the Nursing Home Administrator was unable to explain the lack of documentation for these dates and stated that staff are expected to document after completing treatments. The failure to ensure consistent documentation and administration of ordered wound care treatments led to the deficiency.