Failure to Provide Pressure Ulcer Care per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with multiple pressure ulcers did not receive wound care according to physician orders. The resident, an elderly female with severe cognitive impairment and several medical conditions including stage 3 and stage 4 pressure ulcers, was admitted with existing wounds. The care plan outlined specific interventions such as frequent repositioning, skin inspections, and the use of pressure-relieving devices. Physician orders for wound care, including the use of specific dressings and cleansing routines, were provided on admission and detailed in the resident's records. Despite these orders, the facility failed to enter the wound care orders into the electronic treatment administration record (eTAR) system in a timely manner. As a result, wound care was not documented or possibly not provided from the time of admission until several days later, when the orders were finally entered. Interviews with the wound care nurse, nurse practitioner, and DON confirmed that the orders were not in the system and that it was the responsibility of nursing staff to ensure orders were entered and followed. Documentation showed that at least one scheduled wound care treatment was missed, and there was uncertainty about whether care was provided during this period due to lack of documentation. The facility's policies required that physician orders be recorded accurately and that wound care treatments be performed as ordered. The failure to enter and follow the wound care orders as prescribed led to a lapse in the resident's wound care regimen. This deficiency was identified through record review and staff interviews, which revealed gaps in both documentation and the provision of care as ordered.