Failure to Timely Initiate and Document Wound Care Orders for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to provide evidence that a physician's order for wound care was carried out and documented for two days to treat a facility-acquired pressure injury. A resident with paraplegia, spinal stenosis, and diabetes was noted to have an opening on the sacrum during care. Documentation showed that the nurse cleansed the wound, applied medical honey, and notified the physician and family. However, there was no evidence in the Order Summary Report or Treatment Administration Record that a physician's order for wound care was entered or that wound care was provided on the two days following the discovery of the wound. The wound assessment indicated a stage 2 pressure ulcer on the coccyx, acquired in-house, with specific treatment orders documented only after a two-day delay. Interviews with the ADON and LPN confirmed that the wound care order was not initiated or entered into the computer until two days after the wound was discovered, despite facility policy requiring prompt documentation and implementation of treatment orders. Facility policies also required that all treatments be documented in the medical record, which was not done in this case.