Neglect in Wound Care Leads to Resident Harm
Penalty
Summary
Brethren Village was found to be non-compliant with the requirement to ensure residents are free from neglect, as evidenced by the inadequate wound care provided to a resident with a thoracic spinal cord injury and diabetes. The resident was admitted with an improving Stage 3 pressure ulcer on the coccyx, which required specific wound treatment. However, the facility failed to consistently apply the prescribed treatment, leading to the deterioration of the wound. The facility's records showed that the wound treatment order expired and was not renewed, resulting in missed treatments on several days. Additionally, when a new treatment was ordered, the necessary medication was not available due to a computer entry error, and the staff did not follow up with the pharmacy or notify the physician about the unavailability of the medication. This lack of action led to the wound becoming unstageable, with increased slough and infection, as confirmed by a wound culture. The resident's condition worsened, requiring hospitalization for surgical debridement and intravenous antibiotics. The facility's failure to provide consistent and correct wound care resulted in actual harm to the resident, including unnecessary pain and hospitalization. The deficiency was substantiated by the facility's own investigation, which confirmed neglect by a staff member.
Plan Of Correction
Preparation and submission of the plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Santyl was received January 27th and treatment applied appropriately on that date forward. Education and corrective action provided to team member involved January 27, 2025. Team member terminated 2/6/2025. Team member who did not transcribe medication properly educated and corrective action January 31, 2025. Audits was done on past month of treatments to identify any trends and patterns. Completed February 6, 2025. Licensed staff educated on notification of physician's residents and resident representative if treatment is not available. Completed by February 8, 2025. Order set for wounds added to EMR, education provided to licensed team members on use of order set and documentation. Completed by February 8, 2025. Audits on wound order set began February 13, 2025 x 4 weeks. Wound Policy and procedure was reviewed, updated and wound team educated. Completed by January 30, 2025.