Failure to Obtain Treatment Orders and Implement Care for New Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement pressure ulcer prevention interventions and obtain timely treatment orders after a pressure ulcer was identified. Resident #10 was admitted with diagnoses including heart failure, diabetes mellitus, and muscle weakness. A comprehensive MDS assessment showed the resident was dependent for toileting, showers, and transfers, was occasionally incontinent of bowel, and had no documented skin impairment at that time. The care plan identified the resident as at risk for skin breakdown due to bowel incontinence, an indwelling device, impaired mobility, weakness, and age-related changes, with interventions that included notifying the physician of skin problems so that treatments could be initiated per orders. On 03/02/26 at 10:41 p.m., a nursing progress note documented that an aide discovered a pressure wound on the resident’s coccyx. The nurse assessed the wound, which measured 0.5 cm by 0.2 cm with scant bleeding, and cleaned it with normal saline, applied Vitamin A and D ointment and powder, and placed a dry foam dressing. However, review of physician orders from 03/02/26 through 03/04/26 at 2:00 p.m. showed no treatment orders for the coccyx pressure ulcer. During observation of wound care on 03/04/26 at 2:01 p.m., the RN confirmed there was no treatment in place for the coccyx ulcer and verified there had been no physician orders for wound care or treatment from the time the wound was first observed until that date. This was inconsistent with the facility’s “Prevention of Pressure Injuries” policy, which required evaluation, reporting, and documentation of skin changes and review of interventions for effectiveness.
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