Inadequate Wound Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide consistent and appropriate treatment for an unstageable pressure ulcer for Resident CL1, resulting in wound deterioration, infection, and hospitalization. Resident CL1 was admitted with an improving Stage 3 pressure ulcer and was identified as 'At Risk' for developing pressure ulcers. The care plan included interventions such as turning and positioning, adequate nutrition, and wound treatment as ordered. However, there were missed wound care treatments on specific dates, and the attending physician was not notified of these omissions. The wound deteriorated, becoming unstageable with increased slough and drainage, and a new treatment was recommended. Despite a physician's order for Santyl, the medication was not delivered promptly, and alternative treatments were used without notifying the physician or supervisor. This lack of communication and follow-up led to further deterioration of the wound, which developed tunneling and purulent discharge, indicating infection. A wound culture confirmed the presence of multiple organisms, and the resident was placed on antibiotics and scheduled for a wound clinic consult. The wound was assessed as a Stage 4 pressure ulcer with necrotic tissue and exposed bone, requiring operative debridement and IV antibiotics. The resident was subsequently hospitalized for surgical intervention, highlighting the facility's failure to ensure consistent and appropriate wound care, resulting in actual harm to the resident.
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. All findings to be reported to Quality Assurance Committee. Wound Policy and procedure was reviewed, updated and wound team educated. Completed by January 30, 2025. Education and corrective action provided to Wound Care Certified nurse. (Wound team leader). Wound Care nurse terminated February 5, 2025.