Failure to Provide Ordered Pressure Ulcer Treatments for Three Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care as ordered by physicians for three residents with existing pressure injuries. For one resident with severe protein malnutrition, adult failure to thrive, dysphagia, and a sacral pressure ulcer present on admission, the care plan and wound NP notes specified cleansing the sacrum/buttocks with soap and water, patting dry, and applying Zinc Oxide and collagen particles every shift, leaving the area open to air. Although the wound initially improved in size and remained 100% epithelial tissue, the Treatment Administration Records (TARs) for two consecutive months showed the treatment was documented only on the day shift instead of every shift as ordered. During observation, the resident was found on his side with an open, bloody coccyx wound and no visible cream or bandage. A later wound NP note documented that the Stage 2 ulcer had worsened significantly in size and was described as a Kennedy terminal ulcer, with treatment changed to a collagen silicone bordered foam dressing three times weekly. A second resident, cognitively intact with a history of stroke, dysphagia, and PEG tube, developed a new Stage 2 pressure ulcer to the right buttock. The wound NP ordered cleansing with soap and water and application of Zinc Oxide every shift, to be left open to air, and a physician’s order mirrored this. The TAR for the month showed blanks where the treatment was not signed out as completed on specific day and evening shifts. A subsequent NP note showed the ulcer had increased in size, and a later physician’s order changed the regimen to cleansing both buttocks with soap and water and applying Zinc Oxide every day shift. The TAR for the following month again contained multiple blank entries on day, evening, and midnight shifts where the buttock treatment was not documented as completed. Later NP documentation noted the right buttock ulcer measurements and identified a new open area, described as an abrasion, on the left inner buttock, with treatment changed to a collagen with silver dressing and silicone bordered gauze. A third resident with type 2 diabetes, severe protein malnutrition, stroke, contracture of the right lower leg, and an existing right hip wound was care planned as being at risk for pressure ulcers, with approaches including administering treatments as ordered. The wound began as an abrasion to the right hip and progressed to a full-thickness wound with slough, then to an unstageable pressure injury with increased depth and slough. The wound NP repeatedly adjusted the treatment orders, including cleansing with wound cleanser, then Honey Hydrogel Sheet Dressing, and later collagen with daily and PRN changes. The TAR for one month showed missed documentation of the daily collagen and bordered gauze treatment on two dates. After the wound was noted with undermining and malodor, the NP changed the treatment to cleansing with 0.25% Dakin’s solution, applying collagen with silver, and covering with bordered gauze daily and PRN, and a physician’s order reflected daily shift care. The TAR for the end of that month and into the next again showed blank entries on specific dates where the Dakin’s and collagen with silver treatment was not documented as completed. Throughout interviews, the wound nurse stated that treatments were supposed to be completed as ordered, and the DON had no additional information.
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.