Failure to Document and Complete Ordered Pressure Ulcer Care
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 perform pressure ulcer care and daily skin checks as ordered for one resident with a pressure injury. According to the facility's policy, wound care and skin checks must be documented in the electronic medical record when completed. Review of the resident's Treatment Administration Record showed multiple dates where the prescribed wound care for the left heel and daily skin checks were not signed out as completed. The resident reported that wound care was performed at least daily, but the documentation was inconsistent. The Infection Preventionist/Treatment Nurse confirmed that if treatments are not signed out, they are considered not completed as ordered, and any refusals should be documented in the progress notes.