Failure to Provide Pressure Ulcer Care per Physician Orders and Protocols
Penalty
Summary
The facility failed to provide quality care and treatment for pressure ulcers in accordance with professional standards for one resident. The resident, who had a history of bilateral below-knee amputations and spinal fractures, was observed with multiple wounds, including a large dressing on the sacrum that was not fully intact, an open and actively bleeding wound on the right buttock without a dressing, and a dressing on the right knee. During wound care, it was noted that the prescribed calcium alginate with silver was not applied to the right knee or sacrum wounds, and the dressings used did not match physician orders. The right buttock wound was not covered with the required hydrocolloid dressing, and the LPN providing care was unaware of the specific dressing requirements outlined in the treatment orders. Further review revealed that the resident's care plan did not include all current wounds, specifically omitting the stage 2 pressure ulcers on the coccyx and right knee. Weekly skin observations and documentation were also lacking, with no entries for the past three weeks. The CNA staff relied on incomplete care plans for direct care, and the treatment administration record indicated inconsistencies between ordered and provided wound care. These actions and omissions resulted in a failure to follow physician orders and facility protocols for pressure ulcer prevention and treatment.