Failure to Complete Pressure Ulcer Dressing Changes as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services consistent with professional standards of practice. Specifically, dressing changes for a sacral pressure ulcer were not completed as ordered on three separate dates. Documentation on the Treatment Administration Record (TAR) indicated that wound care was signed off as completed by nursing staff on certain dates, but observation and interviews revealed that the dressing had not been changed and the care was not actually provided. The dressing removed from the resident was dated several days prior, confirming the lapse in care. Nursing staff acknowledged that wound care was not performed as documented and recognized that this was not in accordance with facility expectations or physician orders. The resident involved was an older female with multiple diagnoses, including schizoaffective disorder, vascular dementia with anxiety, pain, and functional quadriplegia. Her care plan included specific interventions for pressure ulcer management, and physician orders detailed the required wound care regimen. Despite these orders, the facility did not ensure that dressing changes were completed as scheduled, and the facility's policy did not provide clear guidance on following wound care orders. Interviews with staff and administration confirmed that the expected standard was not met, and documentation did not accurately reflect the care provided.