Failure to Complete Pressure Ulcer Wound Care as Ordered
Penalty
Summary
A resident with a history of quadriplegia, diabetes, and schizophrenia was admitted and later readmitted to the facility. The resident had multiple stage three pressure wounds, including on the mid-spine, right back, sacrum, and left buttock, all of which were documented as improving. Physician orders required daily wound care, including cleansing with wound cleanser, application of a collagen sheet, and securing with a bordered foam dressing to several wound sites. Survey findings revealed that the wound care dressings for the resident were not completed as ordered. Specifically, the dressings were signed off as completed on the medication and treatment administration records by an LPN, but the actual dressing dates did not match the documentation, confirming that the care was not provided as scheduled. The facility's wound care policy required treatment based on wound characteristics, but the records and staff interview confirmed a failure to follow the prescribed wound care regimen and maintain accurate documentation.