Failure to Timely Update Pressure Ulcer Treatment Orders
Penalty
Summary
A resident with quadriplegia, traumatic brain injury, and cognitive impairment was identified as having a new open area on the right lower buttock, initially assessed as moisture-associated skin damage. The care plan included cleansing the wound, applying medihoney, and covering with an adhesive foam dressing. Despite a wound healing consult noting the area was worsening, there was no documented evidence that the new treatment order to use Hydrofera blue was initiated promptly. The Treatment Administration Record showed that the wound treatment was not updated in a timely manner, and the resident continued to receive the previous treatment for two days after the new order was given. Interviews with the Director of Nursing and a Registered Nurse confirmed that the orders for the resident's worsening wound were not updated as required, resulting in the resident receiving the incorrect treatment. This failure to provide timely and appropriate pressure ulcer care was identified during a review of clinical records and staff interviews, constituting a deficiency under 28 Pa. Code 211.12(d)(5) Nursing Services.