Failure to Provide Consistent Pressure Ulcer Care and Pressure Relief Interventions
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent infection or new pressure ulcers for two residents with existing pressure ulcers. For one resident, staff did not follow the physician's order to cover a sacral wound with a dry dressing when the original dressing became dislodged. During an observation, the wound was found exposed without a dressing, and the nurse on duty was unaware that the dressing had come off. Documentation did not reflect that PRN wound care was provided as ordered. Additionally, the resident's low air loss mattress was set at a weight much higher than the resident's actual weight, and there was no recent weight recorded in the chart to guide proper mattress settings. Another resident with a stage three sacral pressure ulcer did not receive wound care as ordered on multiple dates, as evidenced by blank treatment administration records (TARs) for those days. The resident also did not have a functioning low air loss mattress for pressure redistribution, as the previous mattress was removed after it became nonfunctional and was not replaced. The resident reported that care was less consistent on weekends, and staff interviews confirmed that wound care was not always provided or documented on those days. Both residents' care plans lacked specific information about their wounds and did not address their current wound care needs. Staff interviews revealed confusion about responsibilities for wound care, especially on weekends and in the absence of a dedicated wound care nurse. The facility's own wound care policy required documentation of wound care provided, but this was not consistently done. These failures resulted in residents not receiving wound care and pressure relief interventions as ordered and as required by professional standards of practice.