Failure to Accurately Document and Treat Pressure Ulcers
Penalty
Summary
The facility failed to accurately document and treat pressure ulcers for three residents, resulting in deficiencies in pressure ulcer care. For one resident with multiple diagnoses including heart failure and pneumonia, the admission skin assessment did not include measurements or staging of a sacral pressure ulcer, and physician orders for wound care were not updated to reflect the wound nurse practitioner's recommendations. The Director of Nursing confirmed that the correct orders were not entered or administered, and that the admitting nurse did not properly assess the wound upon admission. Another resident was admitted with chronic ulcers and peripheral vascular disease, but no treatment orders were initiated until several days after admission. Additionally, there were conflicting physician orders for wound care on the left foot, which were not clarified. The Director of Nursing acknowledged the delay in initiating treatment and the presence of inconsistent orders for wound care. A third resident was admitted with a history of heart disease and a recent hip fracture. The admission assessment failed to capture multiple wounds, including a skin tear, surgical incision, and pressure injuries, and treatment orders were not put in place for these wounds. The Director of Nursing confirmed that the wounds were not documented on the admission assessment and that appropriate treatment orders were not established.