Failure to Provide Ordered Daily Wound Care for Pressure Injury
Penalty
Summary
A deficiency was identified when a resident with a deep tissue injury (DTI) on the right heel did not receive wound care as ordered. The resident had a physician's order for daily dressing changes, which was documented in the medical record and the facility's policy required staff to verify and follow such orders. However, review of the Treatment Administration Record (TAR) showed that the dressing change was not completed on a specific date. The Director of Nursing confirmed that the daily wound care order was not followed and acknowledged that the dressing change should have been performed and documented daily. The resident had multiple diagnoses, including sepsis, cellulitis of the right lower limb, a non-pressure chronic ulcer with fat layer exposed, and an abrasion of the left elbow. The resident's cognitive status was moderately impaired, and a Power of Attorney for Healthcare was in place. A Nurse Practitioner documented that the right heel wound had deteriorated, with significant eschar and slough present, and attributed the decline to nutritional compromise. Despite the wound's condition and the clear orders for daily care, the required dressing change was missed, constituting a failure to provide appropriate pressure ulcer care.