Failure to Implement Ordered Pressure Ulcer Treatment
Penalty
Summary
Facility staff failed to provide ordered treatment and services to prevent and heal a pressure ulcer for one resident. The resident was admitted in 2024 with diagnoses including adult failure to thrive, characterized by unintentional weight loss, decreased appetite, poor nutrition, and physical inactivity. On 3/18/25, a weekly skin observation note documented a new skin condition measuring 4 cm by 1 cm on the resident, described as pink in color with no drainage, which was cleansed with wound cleanser and dressed. On 3/20/25, a Wound Doctor assessed this area as a Stage III pressure ulcer on the left buttock and ordered a daily Calcium Alginate dressing. On 3/27/25, the Wound Doctor discontinued the Calcium Alginate dressing and ordered zinc ointment to be applied every shift. Review of the March 2025 Treatment Administration Record showed that facility staff did not implement the Wound Doctor’s 3/20/25 order and continued using wound cleanser instead of changing to the ordered Calcium Alginate dressing from 3/20/25 through 3/27/25. In an interview on 2/4/26, the Regional Director of Clinical Operations confirmed these findings, verifying that the ordered pressure ulcer treatment was not provided during that period.
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