Failure to Consistently Provide and Document Ordered Stage 4 Pressure Ulcer Treatments
Penalty
Summary
Failure to provide ordered pressure ulcer care occurred when nursing staff did not consistently complete or document prescribed sacral wound treatments for a resident with a stage 4 pressure ulcer. The resident, who had spina bifida with hydrocephalus, paraplegia, and impaired mobility, was care planned for a stage 4 sacral pressure ulcer with goals for healing and prevention of infection. Physician orders included Dakin’s solution dressings and later collagen powder with Dakin’s-moistened rolled gauze packing and a silicone super absorbent dressing, to be applied daily and as needed. The Treatment Administration Records (TARs) for December, January, and February showed multiple dates on which these treatments were not documented as administered. Record review identified missing treatment documentation on several specific dates in December, January, and February. Nurses assigned to provide the wound care on some of those dates, including Nurse #4 and Nurse #1, were unable to explain why the treatments were not completed, with Nurse #1 acknowledging that on weekends she could not always administer treatments and would simply not sign the TAR. The wound care nurse reported that the resident had voiced concerns that wound treatments were not being done on some weekends and confirmed that, although she had provided wound care on certain dates, those treatments were not signed off on the TAR. Attempts to interview another nurse responsible for a missed treatment date were unsuccessful. The resident, who was cognitively intact and dependent on staff for toileting, personal hygiene, and rolling, reported that wound treatments were sometimes not administered on weekends and specifically identified a recent date when treatment was not done. Nurse aides stated that when residents asked about wound care, they would notify the nurse and then inform the resident that the nurse was aware. Wound progress notes documented that the stage 4 sacral ulcer initially showed granulation tissue and later periods of deterioration with increased undermining. The physician assistant and wound nurse practitioner both stated that wound treatments are ordered for a reason and that failure to provide dressing changes as ordered could cause the wound to not progress or worsen. The DON and Administrator were not aware that wound treatments were not being administered on some weekend days and stated their expectation that treatments be provided according to physician orders.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.