Failure to Provide Timely Pressure Ulcer Care and Nutritional Assessment
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers or at risk of developing them, as observed during the survey. Resident #1 developed new pressure ulcers, and there was no documented evidence that recommended treatment orders were obtained or implemented in a timely manner. Additionally, diagnostic tests were not ordered or obtained promptly. The resident's condition included dementia, and they required substantial assistance with mobility. Despite having a comprehensive care plan that included interventions for skin breakdown, the facility did not update treatment orders as recommended by the wound physician, leading to worsening of the resident's condition. Resident #1's treatment orders were not updated to reflect the wound physician's recommendations for the sacral ulcer and ischium ulcers. The facility continued to apply treatments that were not appropriate for the resident's current condition, and there was a lack of timely communication and implementation of the wound physician's orders. The resident's condition deteriorated, with the development of significant ulcers and signs of infection, which were not addressed adequately by the facility. The resident was eventually hospitalized and diagnosed with osteomyelitis and sepsis, and later expired. Resident #3 developed a Stage 3 pressure ulcer and experienced significant weight loss. However, there was no documented evidence that the registered dietitian reassessed the resident's nutritional needs in a timely manner. The resident's care plan included monitoring for skin breakdown and nutritional status, but the facility failed to notify the dietitian promptly about the resident's condition. The dietitian's assessment was delayed, and the resident's nutritional needs were not addressed in a timely manner, contributing to the deficiency.
Plan Of Correction
Plan of Correction: Approved February 3, 2025 1. Residents #1 and #3 are no longer residents of the facility. The nurse managers for residents #1 and #3 were provided written education for not following the facilities policy in regard to orders management/transcriptions and weight loss. The dietician was also provided written education on the facility weight loss and wound management policy. 2. A facility wide audit was completed on 12/20/2024 of all residents’ weights. Any identified weight loss was confirmed with a reweight and communicated via documentation in the resident records to the medical provider, dietitian, and then reviewed with MDS. There were no other residents identified with unaddressed weight loss, finding no other residents having been impacted by the deficient practice. 3. A facility wide audit was conducted on 12/06/2024 that included a head-to-toe skin check on all residents to identify skin issues that may have not been documented or with wound care orders. This includes an audit of all residents being followed by an outside wound care service, ensuring that all orders from the most recent visit were transcribed as written. The audit identified that no other residents were impacted. 4. The facility medical orders management policy (#6011) was reviewed, finding it to be appropriate and not followed by staff resulting in deficient practice. The facility weight policy (#8220) was reviewed, found to be appropriate and not followed by staff, resulting in the deficient practice. The skin management policy (#8162) was reviewed and revised to clarify nurse managers expectations of: - Following resident active wounds by documenting the results of the visit in the residents’ record and notifying the medical provider and dietitian. - The required immediate review of the outside wound consultants visits to include transcribing the consultant orders the same day as the visit. - Add a progress note acknowledging that they completed the transcriptions, documentation, and in house medical/dietitian notification of the visit. 5. Education has been given to the nurse managers and DON on medication orders management/transcriptions, consult visits, weight changes, and skin management policy updates. 6. The DON is completing weekly audits while holding a weekly skin and weight meeting with MDS, nurse managers, and the dietitian present. The audit includes: A. Keeping a running list of all active wounds in the facility on a spreadsheet B. Checking that all wound orders including consultant visits for the residents are present and correct weekly on the spreadsheet. C. Checks that the care plans are present and appropriate for all active wounds. D. Ensures dietitian and medical notifications are present in the record from the nurse managers. E. That the dietitian has completed a resident assessment within 72 hours of any new wounds or confirmed weight loss and that recommended supplements are ordered as found appropriate. 7. The deficiency will be brought to the next QAPI meeting and reviewed with the committee. The weekly audit results will also be brought to the monthly QAPI meeting until 90 days of 100% compliance is obtained. The weekly skin and weight meeting with the IDT will remain indefinitely as a new facility process to ensure continued compliance. 8. Weekly audit of all dietitian notes will be pulled and reviewed at the weekly wound and weight management meeting and brought to QA to ensure compliance that resident assessment was completed within 72 hours of any new wounds or confirmed weight loss. After 4 weeks we will move to monthly audits x 3 months. Then review with QAPI to determine the frequency going forward. 9. The DON/designee is responsible for the completion and compliance of this plan.