Failure to Provide and Document Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide timely and appropriate pressure ulcer care for two residents. For one newly admitted resident with a sacral pressure ulcer, staff did not initiate the physician-ordered wound care regimen until two days after admission, despite documentation of the wound on the admission assessment and a standing order for daily treatment. The resident was later sent to the hospital with worsening wounds and a diagnosis of sepsis. Additionally, recommended diagnostic tests by a wound specialist were not completed before the resident's transfer to the hospital. For another resident, the facility did not consistently document or provide daily wound care and failed to ensure regular turning and repositioning as ordered. Multiple instances were identified where wound care was not documented in the treatment administration record, and several shifts lacked documentation of turning and repositioning. The DON confirmed that staff are expected to document wound care and repositioning, but acknowledged the missing documentation and lapses in care.