Failure to Provide and Document Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that a resident received proper treatment for a pressure ulcer as required by facility policy and physician orders. The resident, who had diagnoses including high blood pressure, hemiplegia, and hyperlipidemia, was admitted with a coccyx wound that required specific wound care interventions. Physician orders directed that the wound be cleansed with normal sterile saline, followed by the application of collagen particles, medical grade honey, calcium alginate, and a bordered gauze dressing on a daily basis. These treatments were to be documented on the Treatment Administration Record (TAR). Review of the clinical records and TAR revealed that the prescribed wound care was not documented as completed on two separate occasions during the month. Specifically, there was no documentation of the treatment being performed during the day shift on two different dates, despite active physician orders. During an interview, the LPN Wound Nurse confirmed that the facility did not ensure the resident received the required pressure ulcer treatment as outlined in the orders and facility policy.