Failure to Complete Ordered Wound-Vac and Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatments and to complete wound care as prescribed for one cognitively impaired resident with unhealed pressure ulcers and multiple comorbidities, including diabetes mellitus, osteomyelitis, COPD, and need for assistance with personal care. Physician orders directed specific daily wound care to the right ischium and detailed negative-pressure wound therapy (NPWT/wound-vac) procedures for a sacral wound, including dressing types, application steps, suction settings, and scheduled dressing changes three times weekly, with a wet-to-dry saline dressing as an alternative only if NPWT could not be maintained. The resident’s care plan included interventions for skin breakdown and pressure ulcers, such as treatments per order, monitoring effectiveness, repositioning, and use of a tilt-in-space wheelchair. Review of the Treatment Administration Records showed multiple missed wound treatments and NPWT applications, with no initials indicating completion of the wound-vac on one date in January and missed right ischium treatments and wound-vac dressings on several dates in February. A nurse confirmed that blank initials on the TAR meant the treatments were not completed. During observation of wound care, the wound-vac machine was found sitting in a chair rather than in use, and the dressing on the resident consisted of an ABD pad and gauze instead of the ordered wound-vac dressing. The resident stated the wound-vac should have been in place but could not recall when it was last used. An LPN reported last applying the wound-vac several days earlier, and the NP acknowledged concerns that some wound care had not been completed, noting that the wet-to-dry dressing was intended only as an alternative if the NPWT equipment was not functioning, and there had been no reports of equipment malfunction. The facility’s pressure injury policy stated a commitment to provide evidence-based treatments in accordance with current standards of practice for all residents with pressure injuries.
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