Failure to Provide Physician-Ordered Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide pressure ulcer care and prevention in accordance with physician orders, facility policy, and professional standards of practice, resulting in the development and worsening of pressure ulcers among multiple residents. Clinical records and observations revealed that residents at high risk for pressure injuries, including those with severe cognitive impairment, immobility, incontinence, and complex medical conditions such as anoxic brain damage and tracheostomy status, did not consistently receive prescribed interventions such as turning and repositioning, use of air mattresses, offloading devices, and specific wound care treatments. Documentation was often incomplete or missing, and there was a lack of clarity regarding which wound care treatments were actually administered. For several residents, physician and wound care practitioner orders for specialized mattresses, offloading of heels, and specific wound dressings (such as calcium alginate, Medi honey, Dakin's solution, and Vashe moistened gauze) were not implemented as directed. In some cases, the treatment administration records did not reflect the provision of ordered equipment or wound care, and staff interviews confirmed uncertainty about which treatments were provided. Observations further confirmed that residents were not on air mattresses or receiving heel offloading as ordered, and nurse aide documentation showed minimal evidence of required interventions being performed. As a result of these failures, residents developed new pressure ulcers and existing wounds deteriorated, with documented increases in wound size, depth, and severity, including progression to Stage 4 pressure injuries and the development of additional wounds. The lack of timely and appropriate wound care, failure to follow prevention protocols, and inadequate documentation led to actual harm for multiple residents, as evidenced by the worsening of their pressure ulcers and the development of new wounds.