Failure to Provide Timely Wound Care and Update Care Plan
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident, identified as Resident #3, who was at risk for pressure ulcer development. The resident was found to have an open area on the left buttocks, but the medical team was not notified for five days, and no medical treatments were ordered during this period. The resident's care plan was not updated promptly to address the new skin integrity issues, leading to further deterioration of the pressure ulcer and the development of multiple new skin injuries. The facility's policy on skin care management required timely documentation and notification of new skin issues, as well as adherence to treatment guidelines outlined in the Clinical Practice Quick Reference Guide. However, these protocols were not followed. The resident's baseline care plan included interventions such as nursing treatments per medical orders, preventative skin care products, and regular skin checks, but these were not effectively implemented. The resident's condition worsened, resulting in several facility-acquired pressure injuries, including an unstageable sacral wound and a stage 3 pressure wound on the left ankle. Interviews with facility staff revealed a lack of communication and timely action in addressing the resident's skin issues. Certified Nursing Assistant #1 reported a red area to the team leader, who documented the finding but did not notify the medical team or request immediate treatment. The Clinical Coordinator acknowledged receiving reports of skin issues but did not take further action to expedite wound consultations or update the care plan. As a result, the resident experienced actual harm, though it was not classified as Immediate Jeopardy.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #3: Resident seen by provider and treatments ordered. Care plan reviewed and revised with interventions added. Nurse #3: Nurse was re-educated on the use of the Wound Ulcer Quick Reference Guide, observing the wound, notifying an RN, notifying the provider, getting an order for [REDACTED]. Nurse received disciplinary action. Nurse #4: Nurse did document in the medical record that she notified the medical provider and to leave open to air with no new treatment order. Provider did request wound consult which was ordered. Nurse was re-educated to document the provider's credentials and to add interventions to care plan. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents were assessed for any skin issues to verify any pressure ulcer had a treatment order in place. No issues were found at the time of the audit in (MONTH) and (MONTH) 2024. All elders/patients with a pressure ulcer will be reviewed to ensure there were no other elders/patients found without an assessment, provider notification, or interventions put in place. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? The Wound Ulcer Management Guide has been reviewed and revised to include notification of medical providers. The Wound Ulcer Management Guide was added to the intranet page of the organization home page. Training will be provided to all nurse managers, RN Clinical Coordinator and Senior LPNs, and nursing supervisors regarding wound management guide, notification to medical to obtain treatment orders at time of new open area, use of EMR alerts, and monitoring and tracking in EMR. Policy will be reviewed and revised for skin management. The nursing leader responsible for the unit will review all progress notes, alerts, and orders for wound consults in the last 24 hours Monday – Friday. The day following a weekend or holiday a nursing leader will review all notes since last review and ensure skin management program was followed. New pressure ulcers will be placed on 24 hr. report sheet with location of area. An audit on all residents with pressure ulcers will be done on all to make sure the skin management program has been followed. Nursing administration has coordinated coverage for nursing units when no RN is available on the unit. Will implement a new system to monitor and track wounds through EMR. Will re-educate all Nurse Managers, Clinical Coordinators, Senior LPNs, and supervisors to document any new pressure ulcer and/or interventions on care plan and care card. How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? An audit will be done by Nursing Leaders or designee on every elder/patient with a pressure ulcer to determine if the skin management program has been followed weekly x 8 weeks, monthly x 3, then frequency as determined by QAPI committee. Cynthia Lovetro, RN, CNO responsible for P(NAME)