Failure to Provide Ordered Pressure Ulcer Care and Accurate Documentation
Penalty
Summary
A deficiency occurred when a resident with pressure ulcers did not receive necessary wound care as ordered by the physician. On observation, the resident was found without a dressing on the sacral wound, which was also soiled due to a bowel movement. The responsible LPN acknowledged the absence of the dressing and indicated that the resident would be cleaned and the dressing applied. Additionally, the dressing for the resident's left thigh wound had not been completed, despite being documented as done on the Treatment Administration Record (TAR) by an RN, who later confirmed that the treatment had not actually been performed. The resident's care plan identified altered skin integrity and a risk for further skin impairment due to underlying conditions such as hemiplegia and cardiovascular disease, with hospice services in place. The plan included interventions such as administering treatments as ordered and monitoring for effectiveness. However, the failure to provide wound care as prescribed and the inaccurate documentation on the TAR led to the resident not receiving the necessary treatment and services to promote healing and prevent infection or new ulcers.