Failure to Provide Ordered Pressure Ulcer Care and Documentation
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to provide necessary treatment and services to promote healing for a resident with a stage four sacral pressure ulcer. Clinical record review showed that the resident, who had multiple sclerosis, venous insufficiency, and was dependent on staff for ADLs, had a physician's order for daily wound care, including dressing changes and cleaning. However, treatment administration records revealed multiple instances over three months where there was no documentation that the wound care was completed as ordered. The resident reported that wound care was not always provided as prescribed, and the Director of Nursing confirmed the lack of documentation for both the provision of care and any resident refusals on those dates.