F0686

D

Failure to Obtain Treatment Orders for Identified Pressure Ulcer

Gretna, Nebraska Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain physician orders for treatment of an identified pressure ulcer. Facility policy on Wound Treatment Management, dated 08-2025, required that wound treatments be provided in accordance with physician orders, including cleansing method, dressing type, and frequency, and that in the absence of treatment orders the licensed nurse would notify the physician to obtain such orders. Record review showed that a resident, admitted on a specified date and assessed via the MDS as unable to make themselves understood and needing partial to total assistance with mobility, ADLs, and toileting, had a sacral pressure ulcer measuring 2.0 by 1.0 cm documented on an admission/readmission assessment dated 01-09-2026. However, review of the resident’s Order Summary printed on 03-02-2026 revealed no treatment order for the sacral pressure ulcer. In an interview, an RN confirmed the resident had a sacral pressure ulcer, that the physician had not been notified, and that an order for treatment had not been obtained as required.