Failure to Complete Ordered Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when staff failed to ensure that pressure ulcer treatments were completed as ordered for a resident with multiple sclerosis and a stage IV pressure ulcer of the penis. The physician's order required nightly cleansing, application of Skin Prep and collagen filler, and covering the wound with an ABD pad. Record review showed the treatment was performed on one date, but during observation the following morning, the wound dressing was not in place. The resident reported that the dressing had come off during incontinence care the previous night and had not been replaced. An LPN confirmed that there was no dressing in place at the time of observation. Further review and interviews revealed that staff did not notice or report the missing dressing during incontinence care, despite the dressing being found in the resident's brief. The facility's policy required consistent treatment protocols for pressure injuries to aid healing, but this protocol was not followed. The deficiency was identified during a complaint investigation and affected one of three residents reviewed for pressure ulcers.