Failure to Follow Wound Care Orders for Pressure Ulcer
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to follow wound care recommendations for a resident with an unstageable pressure ulcer to the sacral area. The resident, who was cognitively intact and required assistance with daily care, was identified as being at risk for pressure ulcers. A wound consultation and physician's orders specified that Triad cream should be applied to the sacral wound every shift. However, review of the Treatment Administration Record showed that the cream was only applied daily over a four-day period, rather than every shift as ordered. This was confirmed by the Assistant Director of Nursing, who acknowledged that the treatment was not administered according to the physician's instructions.