Failure to Provide and Document Ordered Wound Care for Resident with Sacral Ulcer
Penalty
Summary
The facility failed to follow its policy to ensure appropriate wound care treatment for a resident with a sacral pressure ulcer. The resident, who is moderately cognitively impaired and has a history of wounds, developed a sacral wound while in the facility and was later diagnosed with MRSA of the sacral bone after a hospital visit. The wound care nurse confirmed that the resident requires daily wound care with Santyl ointment as ordered, and that wound care is to be documented on the Treatment Administration Record (TAR). However, review of the TAR revealed that wound care was not documented or performed on several specific dates. Interviews with staff, including the wound nurse, DON, and infection preventionist, confirmed that the resident did not receive wound care on the identified dates, and that lack of documentation on the TAR indicates the treatment was not done. The facility's policy requires wounds to be assessed and measured at least every seven days and for treatments to be recorded. The failure to provide and document daily wound care as ordered constitutes a deficiency in following the facility's wound care policy.