Deficient Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to ensure proper treatment and monitoring for pressure ulcers for two residents. Resident R1, who was admitted with conditions including peripheral vascular disease, diabetes, and a pressure ulcer, did not receive the required weekly wound assessments for two consecutive weeks. Despite having a care plan that mandated weekly assessments of the pressure ulcer's stage, size, and surrounding skin condition, there were no documented assessments for the weeks of December 25, 2024, and January 1, 2025. This lapse was confirmed by a registered nurse during an interview. Resident R199, admitted with high blood pressure, an infection due to cardiac and vascular device implants, and a stage 2 pressure ulcer, also experienced deficiencies in care. The resident had physician orders for wound care treatments, including the application of MediHoney alginate and a Wound VAC dressing. However, these orders did not specify which wound or body area the treatments were intended for, leading to potential confusion in care. This oversight was confirmed by the Registered Nurse Assessment Coordinator, who acknowledged the facility's failure to specify treatment applications for the resident's pressure ulcer.
Plan Of Correction
Resident #199 wound treatment order was immediately clarified and discontinued per physician. Resident #1 wound treatment order was clarified, skin assessment performed, measurements were documented, and physician notified of findings. To identify other residents that have the potential to be affected, the DON/designee conducted a house audit on all resident wound orders to ensure proper treatment of resident wounds and weekly skin assessments. Any negative findings were addressed. To prevent this from reoccurring, the DON/designee educated licensed nursing clinical staff on observation of skin and wound best practices and wound management. To monitor and maintain ongoing compliance, the DON/designee will review wound documentation and new wound treatment orders 5x weekly for 4 weeks, then monthly for 2 months to ensure appropriate monitoring, documentation, and reporting of resident wounds and weekly skin assessments. Negative findings will be addressed. Ad hoc education will be completed as needed. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.