Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with multiple pressure ulcers received necessary treatment and services consistent with professional standards of practice. Upon admission, the resident had nine wounds, including several stage 3 and stage 4 pressure ulcers and a deep tissue injury. Treatment orders for five of these wounds were not implemented for 12 to 13 days, and there was no documentation on the Treatment Administration Record (TAR) indicating whether wound care was provided to these wounds during that period. Additionally, weekly wound assessments were not completed for five of the nine wounds on a specified date, as required by the resident's care plan and facility policy. The resident was cognitively intact and frequently refused care, preferring to spend extended periods outside and declining to return indoors for wound care and medication administration. Nursing notes documented repeated refusals of wound care and medication, as well as the resident's noncompliance with recommended treatment. Despite these refusals, there was a lack of consistent documentation regarding whether wound care was attempted or provided, and treatment orders for several wounds were delayed. The facility's staff, including the treatment nurse and DON, acknowledged that the absence of timely treatment orders and incomplete documentation could result in wounds not being treated as required. The situation escalated when maggots were discovered in one of the resident's wounds, specifically the right heel, after a period of missed wound care. Interviews with staff confirmed that the resident's wounds were not always assessed or treated due to both the resident's refusals and lapses in staff follow-through with documentation and order entry. The facility's own wound care policy required verification of physician orders and documentation of wound care provided, which was not consistently followed in this case. The deficiency was further substantiated by the lack of admission treatment orders for several wounds and incomplete weekly wound assessments.