Failure to Administer Ordered Pressure Ulcer Treatment Due to Lack of Order Clarification
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of a pressure ulcer for one resident. According to the facility's Clean Dressing Change Policy, wounds are to be dressed using a clean technique, with new dressings applied as ordered and findings documented. The resident in question had a diagnosis of a right heel pressure ulcer and osteoarthritis, with physician orders specifying a wound care regimen involving cleansing, application of betadine and calcium alginate, and securing with an ABD pad three times daily. Clinical record review showed that the prescribed wound treatments were not administered during several night shifts, as documented in the Medication Administration Record. An LPN reported not administering the treatments because the evening shift had noted the need for order clarification, but no clarification was sought throughout the week, resulting in continued omission of care. The DON confirmed that wound treatments should have been administered as ordered and clarified in a timely manner if needed.