Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident, identified as Resident #45, who was readmitted with a pressure ulcer. Upon re-admission, the facility did not conduct a thorough wound assessment as required by their policy. The resident had a documented stage two pressure ulcer on the left trochanter, but the assessment lacked details such as size, depth, and appearance. Furthermore, there were no documented wound care treatments provided for several days, and the resident's care plan was not updated to reflect the pressure ulcer following re-admission. Observations and interviews revealed that the resident had an unlabeled and undated adhesive dressing on the left trochanter, which was not recognized or addressed by the nursing staff. A Licensed Practical Nurse was unaware of the dressing's contents and whether there were any treatment orders for the resident's condition. Certified Nursing Assistants and Licensed Practical Nurses were not adequately communicating or documenting the presence of new skin impairments, and there was a lack of follow-up to ensure proper wound care orders were in place. The Director of Nursing and Registered Nurse #2 acknowledged the oversight in reviewing the hospital's After Visit Summary and the failure to enter necessary wound care orders into the electronic medical record. The facility's policy required a complete body examination and documentation of any skin impairments upon re-admission, which was not fully executed. This lack of adherence to professional standards of practice resulted in the resident not receiving appropriate care to promote healing and prevent the worsening of the pressure ulcer.
Plan Of Correction
Plan of Correction: Approved February 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident # 45 was seen by the provider on 1/10/25 with no adverse effects noted from deficient practice. Treatment orders were placed. 2. All new admissions and all residents with wound treatments have the potential to be affected. Treatment orders will be reviewed for pressure ulcers to validate treatments were provided as ordered by the physician. All other residents with wound treatments ordered will be reviewed by Wound Provider. 3. Policy “Skin and Pressure Injury Prevention and Wound Identification and Wound Rounds” was reviewed with no revisions. The DON/designee will educate licensed nurses currently working at the facility and will be reeducated on wound care management/aseptic dressing changes to ensure proper technique and documentation. All new admissions will be audited for accurate skin assessment and treatments for any and all wounds. Any issues noted will be addressed at the time of identification, including applicable reeducation. All licensed nurses will complete a treatment competency to be evaluated for correct technique, following the treatment orders as prescribed, and infection control practices on hire, yearly, and as necessary. The unit manager will conduct daily routine rounding and review of Treatment record looking at consistent documentation of resident's pressure ulcers, complete and accurate treatment orders, following the treatment orders as prescribed, and [DEVICE] functionality. Any issues discovered will be corrected at the time of discovery. 4. Wound nurse/designee will audit all residents with wounds for presence of correct wound supplies and completion of the treatments as ordered weekly x 12. All findings will be brought to the QAPI committee for review and comment. The DON will provide onsite oversight of the IDT care plan meetings and provide feedback to the Regional Director on the effectiveness of the interventions. Audit results will be forwarded to the QAPI Committee for review and input. Responsible party: The Director of Nursing