Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary pressure ulcer care and prevent new ulcers from developing for three residents with existing wounds. For one resident with a history of neurological conditions, malnutrition, and Alzheimer's disease, the facility did not provide PRN wound care to a right buttocks wound as ordered. Observations revealed the resident was without a dressing on the wound, and interviews with staff indicated a lack of communication and awareness regarding the missing dressing. The wound care nurse and CNA both expected the other to notify or address the missing dressing, and the nurse on duty was unaware of the wound, resulting in the dressing not being replaced as required. Another resident with diabetes and renal insufficiency did not receive daily wound care to a left foot ulcer on two consecutive days. The wound care administration record had blank entries for those days, and the resident reported that her dressings had not been changed as scheduled. The wound care nurse confirmed that the dressing was not changed over the weekend and stated that the charge nurse was responsible for wound care during that time. The DON confirmed that staff were trained to check orders and provide care when the wound care nurse was absent, but the care was not provided as ordered. A third resident with a non-traumatic brain injury and muscle weakness did not receive wound care to a sacrum wound on a scheduled day. The wound care administration record was blank for that day, and the charge nurse responsible was not aware that the wound care nurse was absent. The DON stated that charge nurses were notified in the morning meeting about the wound care nurse's absence, but the wound care was not completed. In all three cases, the facility failed to follow physician orders and professional standards of practice for wound care, as confirmed by record reviews, staff interviews, and direct observations.