Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment for a resident with a stage 2 coccyx pressure injury. The resident was admitted with diagnoses including high blood pressure, muscle weakness, and heart failure, and an MDS assessment was completed. A physician’s order dated 1/13/26 directed staff to cleanse the stage 2 coccyx wound with wound cleanser, pat dry, apply triad paste, and cover with bordered gauze daily. Review of the Treatment Administration Record showed that this ordered treatment was not provided on 1/15/26 or 1/23/26. In an interview on 2/5/26, the Director of Nursing confirmed that the facility failed to provide the pressure ulcer treatments as ordered for this resident. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee, 211.10(c)(d) Resident care policies, and 211.12(d)(1)(2)(5) Nursing services.
