Failure to Complete Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered for two residents with significant medical conditions and wounds. For one resident with a non-pressure chronic ulcer of the right heel and midfoot, medical record review showed multiple missed wound care treatments on specific dates, despite physician orders for daily care involving cleansing, application of collagen, and appropriate dressings. The resident's care plan included interventions for impaired skin integrity, but the treatment administration records (TARs) documented that wound care was not performed on several occasions. Another resident with a history of traumatic brain injury, tracheostomy, and pressure injuries to both feet also did not receive wound care as ordered. Physician orders and TARs indicated missed daily and twice-daily wound care treatments for both the left and right foot on multiple dates. Staff interviews with the DON confirmed that wound care was not completed as required for both residents. Facility policy required the promotion of treatment and healing of skin integrity impairment, but the documented omissions in wound care represented a failure to follow these protocols.