Failure to Provide and Accurately Administer Pressure Ulcer Care
Penalty
Summary
Facility staff failed to provide appropriate pressure ulcer care and prevention for three residents, as evidenced by medical record reviews and staff interviews. One resident with cerebrovascular disease, diabetes, and peripheral vascular disease was admitted with a sacral Stage IV pressure ulcer. After returning from the hospital with specific wound care instructions, the facility did not administer the required daily sacral wound treatments for nearly two weeks, a lapse confirmed by the Director of Nursing. Another resident, admitted for rehabilitation and wound care with multiple chronic conditions including cerebral palsy and diabetes, had a sacral pressure ulcer that progressed to Stage IV and extended to both buttocks. The treatment orders for this resident were incorrectly entered into the electronic medical record, resulting in wound care being performed three times daily instead of the intended once daily. Staff interviews revealed that treatments were performed according to what appeared in the eMAR, without questioning discrepancies, and the wound care physician confirmed the order was for once daily application only. A third resident, admitted for subacute rehabilitation, had deep tissue injuries (DTIs) on both heels. The treatment administration record showed that the wound care provided did not match the wound physician's orders, with incorrect dressings and delayed initiation of the prescribed treatment. The Director of Nursing acknowledged inconsistencies in following wound care orders on the unit. These findings demonstrate a failure to follow prescribed wound care protocols and ensure accurate implementation of physician orders for pressure ulcer management.