Failure to Timely Implement Wound Care Recommendations
Penalty
Summary
The facility failed to provide recommended interventions consistent with professional standards of practice to promote the healing of a pressure ulcer for a resident. The resident was admitted with a skin tear on the sacrum, which was documented by nursing staff. However, subsequent medical provider documentation did not mention the skin tear, and a comprehensive skin assessment later identified a Stage 3 pressure injury. Despite recommendations from a wound care service to treat the pressure ulcer, the facility did not initiate these treatments in a timely manner. The care plan for the resident, which included interventions for skin integrity and the pressure ulcer, was not initiated until after the resident was discharged. Additionally, physician orders for the treatment of the sacral pressure ulcer were dated after the resident's discharge, and there was no evidence in the medication/treatment administration record that the recommended treatments were completed. The facility could not provide documentation that staff were aware of or had implemented the wound care recommendations before the resident's discharge.
Plan Of Correction
1. Resident CR1 was discharged and was unharmed. 2. The Director of Nursing reviewed any current residents who have pressure ulcers to ensure proper treatments are in place and physician orders are being followed for proper wound care treatment. 3. The Director of Nursing provided education to the nursing staff regarding the significance of implementing appropriate wound care treatments and documentation tailored to each resident's needs and ensuring adherence to the established treatment plan. 4. The Director of Nursing or designee will complete weekly wound care audits for four weeks then monthly for three months and present the audits in the monthly QA meeting.