Failure to Maintain Pressure Ulcer Dressing as Ordered
Penalty
Summary
A resident with a chronic right gluteal pressure ulcer did not receive necessary treatment and services consistent with professional standards of practice. The resident, who was severely cognitively impaired and required pressure ulcer care, was observed without a dressing on his pressure ulcer as ordered in his care plan. During an observation, staff found a thick white substance on the resident's buttocks and directly on the pressure injury, but no dressing was in place. The care plan required the administration of treatments as ordered and monitoring the effectiveness by replacing loose or missing dressings. Interviews revealed that both a CNA and an LVN noticed the absence of the wound dressing but did not report it, despite being trained to immediately notify nursing staff of missing dressings for residents with pressure ulcers. The DON confirmed that wounds without dressings increase infection risk and delay healing, and stated that it was the responsibility of the wound care nurse to ensure dressings were in place as ordered. The facility's policy required staff to assess skin routinely and report abnormalities to nursing staff to prevent skin breakdown and promote healing.