Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The Manor at Penn Village was found to be non-compliant with federal and state regulations regarding the treatment and prevention of pressure ulcers. The facility failed to conduct comprehensive skin assessments and implement necessary interventions for a resident identified as at risk for pressure ulcers. Specifically, the facility did not perform weekly skin evaluations as required, nor did they document the size and condition of existing wounds upon admission. A resident, admitted with a self-care deficit and fragile skin, was noted to have moisture-associated skin damage on the buttocks upon admission. However, the facility did not document the size of the wound or conduct further assessments until a significant deterioration was observed over a month later. A full-thickness wound on the sacrum was identified, but the facility failed to provide adequate documentation or monitoring of the wound's progression and response to treatment. Additionally, a pressure ulcer on the resident's heel was not identified until a nurse aide discovered it, despite it being present on admission. The facility did not implement or document the wound care recommendations provided by a third-party service, such as off-loading the wound and using pressure off-loading boots. This lack of timely assessment and intervention contributed to the worsening of the resident's condition.
Plan Of Correction
The facility is unable to retroactively provide comprehensive skin assessments and implement interventions consistent with professional standards of practice, to promote healing of the pressure ulcer for resident CR1. The facility will complete a whole house audit to assess residents for changes in skin condition. All newly identified changes will have implemented interventions consistent with professional standards of practice to promote healing. The DON or designee will educate licensed staff on following physician orders as related to providing comprehensive skin assessments and implementing interventions consistent with professional standards of practice to promote healing. The DON or designee will complete daily audits 5x week x 2 weeks and then weekly x 8 to ensure physician ordered interventions for changes in skin conditions are being followed. Results of those audits will be reviewed monthly at the facilities QAPI.