Failure to Provide Timely and Documented Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention treatments as ordered for one resident. Upon readmission from the hospital, the resident, who was cognitively impaired and required staff assistance for daily care, had an unstageable pressure ulcer on the left heel. There was no documented evidence that the facility obtained a physician's order for wound treatment until two days after readmission, when the resident was seen by a wound consultant. Additionally, after a treatment order was obtained, there was no documented evidence that the prescribed wound care was completed on two specific dates. The Director of Nursing confirmed the absence of documentation for both the timely acquisition of treatment orders upon readmission and the completion of wound care as ordered on the identified dates.