Failure to Obtain Physician Orders and Document Treatment for Admission Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and obtain treatment orders for a coccyx pressure ulcer identified on admission, and failure to place the ulcer and its treatment on the Treatment Administration Record (TAR) for ongoing monitoring. The facility’s own Skin Program Policy required that all residents be fully assessed on admission, that residents admitted with skin areas/pressure ulcers have treatment orders initiated upon admission or readmission, and that an individualized preventative and active skin plan of care be developed. The resident was admitted with cognitive impairment, total dependence for mobility and hygiene, constant moisture, chairfast status, friction and shear problems, and a Braden score of 11, indicating high risk for pressure injuries. On the evening of admission, the admitting LPN documented a coccyx pressure ulcer/pressure injury measuring 4.0 cm x 0.3 cm x 0.5 cm, with redness and an open area, along with other skin issues to the groin, right shin, back of right ankle, and right big toe. Despite identifying the coccyx pressure ulcer, the admitting LPN did not obtain or document any physician orders for treatment of this wound and did not enter a treatment on the physician order sheet or TAR. The LPN reported cleaning the ulcer and applying barrier cream but acknowledged forgetting to place the treatment on the TAR and not documenting the care provided. The LPN stated they attempted to contact the physician on the day of admission but did not document this attempt and made no further attempts to contact the physician on the following two days worked, even though the resident remained under their care. There was no documentation in the progress notes that the physician was notified about the coccyx pressure ulcer or that any treatment orders were received. Other nursing staff and the wound care nurse confirmed that, per facility practice, any pressure ulcer or skin treatment should appear on the TAR so that nurses on all shifts know to assess and treat the area. Multiple LPNs stated that if a pressure injury or treatment is not on the TAR, they would not know it existed or required care. The wound care nurse and DON both indicated that the admitting nurse was responsible for completing the admission skin check, notifying the physician, obtaining treatment orders, and documenting the ulcer and orders on the POS, TAR, and in progress notes, including any attempts to contact the physician. As of the date the resident died, there were still no physician orders or TAR entries for the coccyx pressure ulcer, and the ulcer had not been incorporated into the facility’s ongoing monitoring and treatment systems.
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