Failure to Accurately Assess and Document Gluteal Wound and Treatment Orders
Penalty
Summary
The facility failed to ensure ongoing assessment and accurate treatment orders for wound care for one resident with a new skin tear in the left gluteal sulcus. A complainant reported concerns that the resident had developed a new wound in the left thigh/buttock area and that the facility was not properly addressing it. On observation with a nurse, the wound was seen as a skin tear approximately 3 cm in length in the skin fold where the thigh meets the buttock, and the nurse stated the treatment was triple antibiotic ointment with a foam dressing. Review of the resident’s progress notes showed an entry indicating a new area on the right leg under the buttock in the crease, but subsequent weekly wound assessments on multiple dates did not document the presence of this wound on either buttock or thigh, with the first documented assessment of the wound not appearing until later in the month. Record review showed an order entered earlier in the month for treatment to the right gluteal fold and a wound care consult, but without specified directions for the consult order. A new wound care order was later entered by the wound care nurse for the rear right thigh, directing cleansing with normal saline, application of triple antibiotic ointment, and coverage with border foam once daily. In interview, the wound care nurse stated they had not been made aware of the new wound until the morning of the later observation date and identified the wound as being on the left gluteal side. It was then noted that all treatment orders since the initial date, including the new order, incorrectly indicated the wound was on the right gluteal area. The wound care nurse acknowledged this error. The facility’s provided policy addressed pressure ulcers/skin breakdown and stated that all pressure ulcers or other skin-related issues are to be measured, documented, and subject to continued assessment and management, but the documented practice for this wound did not reflect ongoing assessment or accurate localization in the orders.
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