Failure to Complete Provider-Ordered Pressure Ulcer Treatment
Penalty
Summary
Facility nursing staff failed to complete a provider-ordered treatment for a pressure ulcer on a resident's left buttock. The resident had diagnoses including paranoid schizophrenia, diabetes, and chronic pain syndrome, and was assessed as moderately impaired in cognitive skills. The resident was identified as being at risk for pressure ulcers and had a provider order to cleanse the open area, apply barrier cream, and cover with a bordered gauze dressing daily and as needed. On one occasion, the treatment was not completed as ordered, with documentation indicating that the LPN was unable to perform the wound care due to increased patient load. The provider order for the wound care was discontinued the following day after the wound was assessed as healed. The deficiency was identified through staff interview, clinical record review, and facility document review, and was discussed with facility leadership during an end-of-day meeting. No additional information regarding the missed treatment was provided to the survey team prior to the exit conference.