Failure to Provide Ordered Sacral Skin Treatment Due to Order Entry Error
Penalty
Summary
The facility failed to provide ordered treatment for a resident who developed an excoriated, slightly reddened area on the sacrum. According to the facility’s policy on Prevention and Treatment of Skin Issues, residents at risk for impaired skin integrity and pressure ulcers are to be properly identified, assessed, and provided appropriate treatment modalities. Progress notes documented that on 2/15/26 a CNA notified an RN of the skin issue, the RN assessed the resident, identified the excoriated sacral area with no drainage, notified the DON, wound care nurse, and responsible party, and obtained an order to cleanse the area with wound cleanser, pat dry, and apply zinc oxide every shift until healed. Record review of the Medication Administration Record and Treatment Administration Record for February 2026 showed no documentation that the ordered sacral treatment was ever provided. During interview and concurrent record review, the RN confirmed there was no documentation of the treatment and stated she did not know why the treatment had not triggered on the MAR/TAR, agreeing that failure to perform the treatment could have caused worsening of the area. The DON stated that although daily review of orders is conducted, the treatment order was missed and did not trigger to the MAR/TAR because an incorrect order type was selected when the order was entered on 2/15/26. The resident, who had diagnoses including diabetes mellitus and cerebral infarction and had been admitted in 2019, was later sent to the emergency department for a change in level of consciousness and did not return, with discharge documented on 2/25/26.
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