Failure to Follow Pressure Ulcer Care Policies and Physician Orders
Penalty
Summary
The facility failed to follow its own policies and physician orders regarding pressure ulcer care for a resident with multiple wounds. The resident, who had significant comorbidities including type II diabetes, protein malnutrition, ventilator dependence, muscle wasting, and incontinence, was identified as being at high risk for skin integrity issues. Despite care plans and physician orders specifying weekly wound measurements, documentation, and specific wound treatments, there were multiple instances where these were not followed. Treatment administration records showed missing documentation for wound care on several days for multiple wounds, including the sacrum, occipital area, left posterior knee, right ischium, right posterior thigh, and left forehead. In some cases, there was no documentation of treatments being administered at all, and in others, the treatments documented did not match the physician's recommendations or orders. Interviews with facility staff, including the DON and wound nurse, revealed that they were unable to locate documentation for several wound treatments and assessments, and could not explain discrepancies between physician orders and what was recorded in the treatment administration records. The DON confirmed that if a treatment was not documented, it was considered not done. Additionally, the wound care nurse was responsible for updating treatment orders after wound specialist visits, but this was not consistently completed. There was also a lack of weekly wound assessments and measurements for some wounds, and outdated or discontinued treatment orders remained in the resident's record without being updated or removed. Facility policies required weekly wound evaluations and documentation, as well as prompt updating of treatment orders following wound specialist recommendations. The failure to document treatments, update orders, and perform required assessments resulted in the facility not providing the necessary care and services to prevent and heal pressure and non-pressure wounds for the resident, as required by professional standards and the facility's own policies.