F0686

E

Failure to Provide Ordered Daily Pressure Ulcer Treatments

Luling, Louisiana Survey Completed on 03-25-2026

Penalty

Fine: $13,505

Summary

The deficiency involves the facility’s failure to provide physician-ordered daily pressure ulcer treatments for three residents with documented pressure injuries. The facility’s Wound Care Protocol required that residents with wounds receive wound care as ordered by the physician. Resident #7 had a care plan and physician’s orders for daily treatment of a Stage IV sacral pressure ulcer, including cleansing with wound cleanser, application of Dakin’s solution–soaked gauze, Santyl ointment, calcium alginate, and a silicone foam border dressing, with dressing changes daily and as needed. On observation, the sacral dressing was dated 03/20/2026, and the Treatment Administration Record (TAR) showed no documented wound care on 03/21/2026 and 03/22/2026. The treatment nurse and the LPNs assigned on those dates each confirmed that the ordered wound care was not provided.

Resident #16 had a diagnosis of a Stage II sacral pressure ulcer with physician’s orders, dated 02/18/2026, for daily wound care. The ordered regimen included cleansing with wound cleaner, patting dry, applying Santyl ointment and calcium alginate, and applying Collagenase ointment to the sacral wound every day shift, with a silicone foam border dressing to be changed daily and as needed if soiled or dislodged. The resident’s care plan included an intervention to administer daily wound care as ordered. Review of the March 2026 TAR showed that the daily wound care was not completed on 03/21/2026 and 03/22/2026. On observation, the sacral dressing was dated 03/20/2026, and the treatment nurse, DON, contracted wound care nurse practitioner, and an LPN all acknowledged that the daily wound care ordered by the physician was not performed on those days.

Resident #44 had a care plan and physician’s orders for daily treatment of a Stage III right heel pressure ulcer. The orders included cleansing the right heel pressure injury with wound cleanser, patting dry, applying Santyl ointment to the wound bed, covering with a silicone foam border or equivalent dressing, changing the dressing daily and as needed, and applying Collagenase ointment to the right heel every day shift. Review of the March 2026 TAR revealed that wound care to the right heel was not completed on 03/21/2026 and 03/22/2026. Observation showed the right heel dressing was dated 03/20/2026. The treatment nurse, DON, contracted wound care nurse practitioner, and the LPNs assigned on those dates each confirmed that the resident did not receive the ordered daily wound care to the Stage III right heel pressure ulcer on those days.