Failure to Provide Ordered Pressure Ulcer Treatments and Timely Diagnostic Testing
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident who was admitted without any pressure ulcers. The resident developed an open area on the left buttock, which progressed to a Stage III pressure ulcer, and also developed a deep tissue injury (DTI) on the right heel. The wound nurse practitioner ordered specific treatments for the right heel, including cleansing with wound cleanser, application of skin prep twice daily, and use of offloading foam heel boots. Additionally, an x-ray of the left buttock and sacrum was recommended to rule out osseous changes. Despite these orders, a review of the resident's physician orders and treatment administration records revealed that the right heel DTI treatments were neither ordered nor administered from the time of the initial wound nurse practitioner's order through the resident's discharge. Furthermore, the x-ray recommended by the wound nurse practitioner was not completed prior to discharge, with the order for the x-ray not being placed until several days after the recommendation. These failures were confirmed through interviews with facility staff, including the x-ray staff and the Director of Nursing.