Failure to Follow Ordered Pressure Ulcer Treatment Regimen
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment for a resident with a Stage 3 coccyx pressure ulcer. The resident had diagnoses including muscle weakness and a need for assistance with personal care, and had a physician’s order dated 1/8/26 to cleanse the coccyx area with normal saline/Vashe, pat dry, apply Santyl, then apply calcium alginate ag and cover with a dry dressing daily and as needed. The facility’s wound management policy required that residents with wounds receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure injuries. Review of the wound report showed the resident had a Stage 3 coccyx pressure ulcer during the review period. On observation, an LPN changed the resident’s soiled coccyx dressing by cleansing the wound with wound cleanser, packing it with calcium alginate, and covering it with bordered gauze, but did not apply Santyl as ordered. In an interview, the Nurse Consultant/Interim DON stated that when a dressing is changed at a non-routine time due to soiling, staff should still apply the treatment as ordered.
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