Failure to Complete Pressure Ulcer Treatments as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered for three residents with pressure ulcers. For one resident with a history of osteomyelitis and stage 4 sacral pressure ulcer, the wound nurse was observed using Dakin's solution instead of the physician-ordered Anasept for wound care, and the treatment administration record (TAR) showed missed documentation of treatments on several days. The wound nurse also did not follow the correct treatment protocol for the resident's right ankle, and the director of nursing confirmed that the treatments should have been completed as ordered. Another resident, who was dependent on staff for bed mobility and had multiple comorbidities including bone cancer and diabetes, was observed with undated and soiled bandages on his left hip and both feet. The left heel bandage, which should have been changed according to updated physician orders, was found to be old, with dried blood and necrotic tissue present. The wound nurse could not verify if the bandage had been changed since the order update, and indicated that wound care was not consistently performed on weekends. The director of nursing acknowledged that wound and skin treatments should be done as ordered. A third resident with vascular dementia and multiple pressure ulcers was observed with outdated bandages and received incorrect wound care. The wound nurse was unaware of a recent change in the treatment order for the right medial distal foot and did not apply the newly ordered Mupirocin ointment. The TAR indicated that treatments were signed out as completed on days when the correct treatment was not provided. The director of nursing confirmed that treatments should be administered as ordered by the physician.