Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent and promote healing of pressure ulcers for two residents. For Resident #3, the Wound Care Nurse (WCN) did not follow proper procedures during wound care, including failing to perform hand hygiene after removing a dirty dressing and before cleansing the wound. The resident, who has cerebral palsy, malnutrition, and contractures, expressed pain during the procedure, indicating a lack of assessment of the resident's tolerance to the treatment. The care plan for Resident #3 included specific interventions for skin checks and the use of supportive devices, but these were not adequately followed during the observed wound care session. For Resident #1, the facility did not implement preventative measures to minimize the development of pressure wounds. The resident was admitted for rehabilitation after a cervical fracture and initially had intact skin with no pressure wounds. However, the resident developed pressure wounds on the heels, which were not documented or staged in a timely manner. The WCN noted that the resident preferred to stay on their back due to a cervical collar, but there was no documentation of refusal to offload the heels or use preventative measures like offloading boots or skin prep before the wounds developed. The investigation revealed that the facility's staff were aware of the residents' conditions and preferences but failed to take appropriate actions to prevent and manage pressure ulcers. The lack of documentation and adherence to care plans contributed to the development and inadequate treatment of pressure wounds in both residents.
Plan Of Correction
F686, Treatment/Svc to prevent/ heal 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1, no longer resides in the facility, discharged on. Resident #3 was immediately assessed by a licensed nurse for any adverse effects related to the alleged deficient practice; none were noted. The Attending Physician and care ARNP were immediately notified, orders for treatment received, and treatment initiated on. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; A quality review of current residents' skin was completed by the nurse practitioner/designee on to ensure no new skin issues were noted and required treatment. Any issues identified were immediately corrected. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not reoccur. The Assistant Director of Nursing/designee initiated education on the components of the Failure to provide necessary care and services to prevent and promote healing, with emphasis on providing treatment to ensure the healing of. Newly hired nurses will be educated on the components of Failure to provide necessary care and services to prevent and promote healing, with emphasis on providing treatment to ensure the healing of by the Assistant Director of Nursing/designee at orientation as part of the systematic changes. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. The Assistant Director of Nursing/designee will conduct random audits of 5 residents to ensure that their treatment and services have been provided according to their Physician Orders, 2x a week for 4 weeks, then 1x a week for 4 weeks, and then monthly for 1 month to ensure compliance. The findings of these quality monitoring will be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance has been met. F 686