F0686

D

Failure to Provide Ordered Daily Treatment for Stage 3 Pressure Injury

Cheswick, Pennsylvania Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident with a Stage 3 pressure injury received ordered wound care treatment in accordance with facility policy and professional standards of practice. Facility policy on Pressure Injury Prevention and Management dated January 2026 stated that residents admitted with existing pressure injuries would receive necessary treatment and services to promote healing and prevent infection. The resident was admitted with multiple wounds, including a Stage 3 pressure injury to the left first finger, surgical wounds to the left leg (BKA) and left thumb (amputation), and vascular wounds to the right knee, right lateral shin, and right dorsal foot. A nursing progress note documented that the wound team assessed the resident shortly after admission, that the resident was alert, cooperative, and in no acute distress, and that new treatment orders were obtained for the various wounds, including medihoney and dry dressing for the Stage 3 pressure injury to the left first finger.

A physician order dated 9/29/25 directed that the left first finger wound be cleansed with normal sterile saline, patted dry, treated with a thick layer of medihoney, and covered with a dry dressing daily. Review of the October 2025 MAR showed that this ordered treatment was not signed off as completed or refused on multiple dates (10/4, 10/7, 10/12, 10/17, 10/18, and 10/29). Review of the November 2025 MAR showed additional missed documentation of completion or refusal on 11/3 and 11/4. During an interview, the Nursing Home Administrator confirmed that the facility failed to ensure that the resident received proper treatment for the pressure ulcer, resulting in a deficiency under applicable Pennsylvania regulations regarding licensee responsibility, resident care policies, and nursing services.