Failure to Timely and Accurately Initiate Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to ensure that pressure ulcer treatment orders were initiated, ordered, and implemented in a timely and accurate manner for three residents reviewed for pressure ulcer care. For one resident admitted with a stage 3 pressure ulcer, the facility did not initiate the wound physician's order for Hydrocolloid paste until 10 days after it was prescribed, instead providing only barrier cream during that period. The DON confirmed that both treatments were available in-house, but staff confusion regarding the correct product led to the delay in appropriate care. Another resident admitted with a stage 4 pressure ulcer had two overlapping and conflicting treatment orders for the same wound over a two-day period. The resident received orders for both a foam border dressing and Mesalt with gauze, resulting in a lack of clarity regarding which treatment should have been provided during that time. The DON verified the presence of these concurrent orders. A third resident with two stage 3 pressure ulcers did not have any treatment orders in place for two days following the wound physician's assessment and recommendation for Hydrocolloid paste. The DON confirmed that there was a gap between the wound assessment and the initiation of the appropriate treatment orders. Facility policy required evidence-based treatments in accordance with current standards of practice for all residents with pressure injuries, but this was not followed in these cases.