Failure to Document and Complete Pressure Ulcer and Wound Care Treatments
Penalty
Summary
The facility failed to accurately assess and document pressure ulcer care for two residents. One resident, with a history of chronic obstructive pulmonary disease, hypertension, and anxiety, was admitted with an unstageable pressure ulcer. Physician orders directed specific wound care, including cleansing, application of betadine, and leaving the wound open to air with changes every shift. However, treatment administration records showed multiple dates where the prescribed wound care was not documented as completed over two consecutive months. Another resident, with diagnoses including chronic obstructive postlaminectomy syndrome, diabetes mellitus, and morbid obesity, had a lumbar spine surgical wound. Physician orders required daily wound cleansing and dressing changes. Treatment administration records for this resident also revealed several dates where the required wound care was not documented as completed. The Director of Nursing confirmed that the facility failed to complete treatments as ordered for both residents.