Failure to Provide Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer prevention and care for a resident, as evidenced by the lack of prescribed skin protective devices and interventions. The resident, who was admitted with multiple medical diagnoses including a stage three pressure ulcer, was observed without a low air loss mattress or heel boots, despite physician orders and wound care consultant recommendations for these interventions. The resident reported not receiving the special mattress or boots and was using a pillow for offloading instead. The Licensed Practical Nurse confirmed the absence of these prescribed devices, indicating a failure to implement the necessary measures to prevent further skin breakdown. The resident's medical records and care plan highlighted the need for specific interventions to manage and prevent pressure ulcers, including the use of a customized shoe, foam heel protector boots, and a low air loss mattress. Despite these documented needs and recommendations, the facility did not provide the required equipment, as confirmed by both the resident and staff interviews. The Director of Nursing acknowledged the purpose of these interventions was to prevent worsening of the wound or new pressure ulcers, yet the facility's actions did not align with the established care plan and physician orders.
Plan Of Correction
1. Residents affected by the deficient Orders were discontinued for NuExec Order 26.461 and no NJ Exec Order 26.4b1 was in place per recommendation as NJ Exec Order 26.4b1 had been NU EX Order 26. as of NJ Exec Order 26.4b1 rounds and NJ Exec Order 26.4b1 rounds, NJ Exec Order 26.4b1 was NJ Ex Order 26.4. 2. Identifying other residents who could be affected by the deficient practice: All residents with wounds and that are at risk for wounds. Residents with wounds were audited to ensure that all orders and recommendations were carried out. No further issues identified. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Unit Managers and Licensed nurses were educated on the Administration of Wound treatments by Assistant Director of Nursing. 4. Monitoring the continued effectiveness of the systemic change: The Director of Nursing/designee will conduct an audit of all wound consults to ensure all orders/recommendations were followed weekly x 4 weeks then monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.