Failure to Ensure Accurate Pressure Ulcer Treatment and Documentation
Penalty
Summary
The facility failed to ensure that a resident with an unstageable sacral pressure ulcer received care consistent with professional standards of practice. The resident's clinical record showed changing wound care recommendations over several weeks, including the use of medical grade honey, Santyl ointment, and Dakins-moistened gauze. Despite updated wound care orders, the treatment administration record (TAR) indicated that nursing staff continued to sign off on both the discontinued honey treatment and the newly ordered Santyl treatment for several days. This overlap occurred because the honey order was not immediately removed from the system while the facility awaited the arrival of Santyl from the pharmacy. Nursing staff reported using honey until Santyl became available, then switched to Santyl as per the updated order. However, documentation on the TAR did not accurately reflect the treatments administered, as staff continued to sign off on both treatments even after the order had changed. The DON acknowledged that this was an oversight and that staff should have clarified the treatment order and accurately documented the care provided. This failure to ensure accurate and consistent wound care documentation and administration led to the deficiency.