Failure to Document and Properly Apply Pressure Ulcer Dressings
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards and its own wound care policy for two of four residents reviewed. Specifically, nursing staff did not document the date and their initials on wound dressings after performing treatments, as required by facility policy. Observations revealed that dressings on multiple wound sites, including the sacrum, bilateral heels, and right ischium, lacked this essential documentation. Interviews with the wound treatment nurse and a CNA confirmed that the dressings were missing the date and initials, and the nurse was unaware of who performed the treatments on certain days. The absence of this information was acknowledged as important for tracking when treatments were performed and for monitoring wound drainage over time. Additionally, the facility failed to ensure that wound dressings were large enough to fully cover and protect the wounds for one resident. An observation showed that a sacral wound dressing did not extend past the edges of the wound, leaving a significant portion of the wound exposed to air and potential contaminants. Both the wound treatment nurse and nurse practitioner confirmed that dressings should fully cover wounds as ordered, and that the observed practice did not meet this standard. The Director of Nursing and facility administrator also confirmed that dressings should completely cover wounds and include the date and initials of the person performing the treatment.