Failure to Provide and Document Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents at risk for skin breakdown. For one resident dependent on a ventilator, the admission and re-admission skin assessments documented an excoriation to the sacrum, but there was no evidence of a physician's treatment order for this area. The resident was later transferred to the hospital, where a Stage II pressure injury to the sacrum was identified. Both the admitting nurse and the Director of Nursing Services acknowledged that no treatment order was obtained or implemented for the excoriated sacrum, despite facility expectations for skin assessment and treatment orders upon admission. For another resident admitted with multiple pressure ulcers, including a sacral stage II ulcer and ulcers in the gluteal folds, the physician's wound treatment orders were entered into the computer system but were not transcribed onto the Treatment Administration Record (TAR). As a result, the prescribed treatments were not available for staff to administer as ordered. The Director of Nursing Services was unable to provide evidence that the wound treatments were implemented for these pressure ulcers.