Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with heart failure and hypertension, who had a stage 4 pressure ulcer on the sacral region, did not consistently receive necessary wound care treatments as ordered. Clinical record review showed that wound vac changes, wet to dry dressings, and other prescribed treatments were not always documented as completed on the Treatment Administration Record (TAR) for multiple dates. Nursing progress notes indicated that on certain occasions, wound care supplies were unavailable, the wound nurse was not present, and attempts to contact supervisory staff were unsuccessful. There were also instances where the wound vac was not functioning and no alternative dressing was documented as applied, despite orders to do so. Further review of the TAR revealed additional missed or undocumented wound care treatments, including a day when a prescribed wound treatment was left blank, indicating it was not performed. During a staff interview, the Nursing Home Administrator acknowledged the lack of documentation and stated that she expected staff to document all completed treatments. The findings demonstrate that the facility failed to ensure the resident received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer.