Failure to Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to assess and treat pressure ulcers according to accepted standards of care for a resident who was admitted and receiving hospice services. Although a nurse practitioner identified a stage II pressure ulcer on the sacrum and provided specific wound care orders, these orders were not included in the resident's Treatment Administration Records (TARs) or Medication Administration Records (MARs) for the relevant months. The first full assessment of the coccyx pressure ulcer was not documented until two days after its identification, and there was no evidence that the prescribed wound care was administered as ordered. Additionally, a subsequent skin check identified a new deep tissue injury to the right heel and a blister to the left scapula, with new treatment orders written for these conditions. However, these orders were also not reflected in the resident's TAR or MAR, and there was no documentation that the treatments, including the application of heel boots, were carried out. The Director of Nursing confirmed the lack of timely assessment and documentation, as well as the absence of evidence that physician orders were followed.