Failure to Follow Updated Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide pressure ulcer treatment according to current physician and CRNP orders for one resident with a right heel pressure ulcer. A quarterly MDS for this resident showed confusion, extensive assistance needs for daily care, and the presence of pressure ulcers. A CRNP wound nurse note documented that the treatment for the right heel pressure ulcer was changed from Gentamicin to Calmoseptine on February 3, 2026, and a physician’s order dated February 4, 2026, specified cleansing the right foot with soap and water, applying Calmoseptine, then a heel cup, with daily dressing changes. However, review of the February 2026 TAR showed that as of February 10, staff continued to apply Gentamicin ointment to the right heel pressure ulcer in the evenings while also applying Calmoseptine in the mornings, resulting in both ointments being used instead of only Calmoseptine as ordered. In an interview, the Regional Nurse confirmed that Gentamicin should have been discontinued when the treatment was changed, but it was not, and staff continued to apply both treatments.
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