Failure to Complete and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered pressure injury treatments were both completed and documented for two residents with pressure ulcers. For one resident with diabetes, peripheral vascular disease, and intact cognition, the EMR showed an order for daily and PRN wound care to a stage 3 pressure ulcer on the left second toe, including cleansing with normal saline and application of silver sulfadiazine 1% and calcium alginate. The resident’s care plan identified risk for impaired skin integrity and a stage 3 pressure ulcer to the left second toe, with an intervention to provide skin care per facility guidelines. Review of the Treatment Administration Records (TARs) for December and January revealed multiple dates on which the ordered toe wound treatment was not signed off as completed and remained without documentation, and there was no documentation provided that the treatments were completed on those dates. A second resident, admitted with osteomyelitis and diabetes and assessed as severely cognitively impaired, had been admitted with a stage 2 pressure ulcer that received treatment. The EMR contained an order for daily and PRN wound care to a sacral pressure injury, specifying cleansing with normal saline and application of silver sulfadiazine 1% and calcium alginate. The care plan documented an unstageable sacral wound and included an intervention to administer treatments as ordered and monitor for effectiveness. Review of this resident’s TARs for December and January showed that the sacral wound treatment was not signed off as completed on several dates and remained without documentation, with no evidence provided that the treatments were completed on those days. Interviews with staff further clarified the actions and inactions leading to the deficiency. The wound treatment nurse reported she was responsible for wound treatments Monday through Friday and that other wound care nurses completed treatments on weekends, with floor nurses expected to complete treatments if the wound nurse was absent and notified by text. She stated she had been sick on one of the dates in question but otherwise did all wound treatments, and acknowledged she was “bad at documenting” treatments on the TAR. Floor LPNs reported they did not sign off wound treatments because wound nurses completed them and that they had not received text notifications instructing them to perform wound care on the dates in question, despite having worked those days. The DON stated that, in general, wound care was considered not completed if it was not documented and that wound care was expected to be documented as completed, consistent with facility policies on wound management and documentation expectations.
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