Failure to Provide and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide and document necessary pressure ulcer treatments in accordance with physician orders and facility wound care policy for three residents with pressure injuries. The facility’s wound care policy required documentation in the medical record of the type of wound, date and time wound care was given, changes in condition, resident complaints, and refusals with reasons. One resident with spinal stenosis, diabetes, hypertension, and peripheral vascular disease had a documented Stage 4 coccyx wound, with physician orders to cleanse with normal saline, apply collagen with silver, and cover with bordered gauze every day on the day shift. Review of the February Treatment Administration Record (TAR) showed no documented wound treatments on three specific dates, despite the standing daily order. A second resident with diabetes, general weakness, and hyperlipidemia had a Stage 3 coccyx pressure area with orders to cleanse with normal saline, apply hydrofera blue, and cover with bordered gauze every day on the day shift; the February TAR lacked documentation of wound treatments on four specified dates. A third resident with diabetes, COPD, morbid obesity, and hyperlipidemia had a Stage 3 sacral pressure area with orders to cleanse with normal saline, apply collagen particles, and cover with a bordered dressing every day on the day shift; the February TAR showed missing wound treatments on three dates. During interviews, an LPN stated that wound treatments are documented on the TAR and that, unless the area is directly assessed, there is no other way to know if treatments were done. When asked, the ADON could not provide proof of wound treatments for the three residents, and surveyors informed facility leadership that the facility failed to ensure residents received necessary treatment and services consistent with professional standards to promote healing of pressure ulcers.
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