Failure to Complete Ordered Wound Care for Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to complete ordered wound care treatments for a resident with multiple pressure ulcers. Resident E had diagnoses including schizophrenia, dementia, anxiety disorder, and a hip fracture, and a significant change MDS showed moderately impaired cognition with delusions. A care plan documented that the resident was readmitted with an unstageable pressure ulcer to the sacrum/coccyx, with interventions specifying that wound treatment was to be provided as ordered. A physician order directed that Dakins 0.125% solution be applied to the coccyx every shift, with cleansing using Dakins-dampened Kerlix, application of Therahoney to the sacrum, and coverage with a Mepilex dressing. Review of the January MAR showed that the ordered coccyx wound treatment lacked completion initials on three separate dates, indicating the treatment was not completed as ordered. A QMA confirmed that if medications or treatments were not initialed on the MAR, it meant they had not been completed. An LPN similarly stated that medications and treatments were to be completed as ordered by the physician and initialed on the MAR or TAR, and that a lack of documentation indicated the treatment had not been done. The facility’s policy provided by the Administrator stated that care and services were to be provided as ordered by the physician, which was not followed in this case.
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