F0686

D

Failure to Transcribe and Implement Physician-Ordered Pressure Ulcer Treatments

Mount Sterling, Illinois Survey Completed on 01-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure physician-ordered pressure ulcer treatments were transcribed to the treatment administration records (TAR) and implemented for a resident readmitted with multiple pressure ulcers. The facility’s policies on Pressure Ulcer Prevention, Identification, and Treatment and on Physician Orders require that pressure ulcers be assessed, physician orders obtained and processed, and treatments recorded with specific details and carried out by nursing staff. Upon readmission from the hospital, the resident’s skin inspection documented pressure ulcers on the right and left toes, coccyx, and bilateral buttocks. Hospital discharge orders directed daily betadine application to bilateral toe ulcers, use of offloading pressure-relieving boots, alginate and foam dressings to all buttock ulcers with changes every three days, and repositioning every two hours using a wedge.

Despite these orders, the resident’s TAR contained no documentation of the ordered pressure ulcer treatments to the bilateral buttocks, coccyx, or toes until eight days after readmission. During a subsequent observation, the wound nurse was seen providing wound care, including zinc application to buttocks ulcers, skin prep to toe ulcers with dark brown scabs, and sodium hypochlorite solution dressings to an unstageable coccyx wound with slough and drainage. In an interview, the DON acknowledged assisting with the readmission orders and stated it was partly her fault that the pressure ulcer treatments were missed, confirming that no pressure ulcer treatments were placed on the TAR and that the resident did not receive the ordered treatments until several days after readmission, and that this lapse should have been noticed earlier.