Failure to Consistently Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement physician-ordered pressure ulcer treatments for a cognitively intact resident with multiple stage 4 pressure injuries. The resident, who has paraplegia and pressure ulcers of the sacral region and right hip, reported that on several days the ordered wound care was not performed, despite orders for daily dressing changes due to large, heavily draining stage 4 wounds. The resident stated that he waited for staff to come at any time during the day, did not call to remind the nurse, and sometimes fell asleep while waiting, resulting in days passing without the treatment being done. Record review confirmed that the resident’s comprehensive care plan and current care plan included pressure ulcer treatments per physician orders, with goals for the wounds to remain free of signs and symptoms of infection and to continue healing without complications. The wound care coordinator/LPN stated that wound care is documented on the Treatment Administration Record (TAR) and that staff nurses are responsible for completing wound care when the wound care nurse is not working. The January TAR showed multiple dates on which the resident’s wound care treatments were not administered as ordered. Facility guidelines state that residents with pressure ulcers are to receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing.
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