Failure in Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to ensure proper treatment and monitoring for pressure ulcers for two residents, R47 and R60. Resident R47, who was admitted with diagnoses including high blood pressure and dementia, had a Stage 2 pressure ulcer on the right buttock. Despite a nursing progress note indicating the presence of an open area, there were no documented wound assessments for several weeks. A telehealth visit was scheduled, but due to staff oversight, the wound practitioner could not assess the wound, leading to a documentation gap. The care plan for the resident's deep tissue injury was not developed until over a month after the injury was identified. Resident R60, admitted with high blood pressure and peripheral vascular disease, had a physician order for wound care on the sacrum. However, the treatment was not consistently documented as completed on multiple occasions. Additionally, a Wound Management Detail Report was not completed for specific weeks, indicating a lack of proper monitoring. The Regional Director of Clinical Services confirmed the facility's failure to provide adequate treatment and monitoring for Resident R60's pressure ulcer. The deficiencies highlight the facility's failure to adhere to its own policies and professional standards of practice regarding pressure ulcer prevention and treatment. The lack of timely care planning and consistent documentation contributed to inadequate care for the residents, as confirmed by staff interviews and clinical record reviews.
Plan Of Correction
R47 was assessed and added to weekly wound rounds. R60 no longer resides at the facility, unable to correct. To identify other residents that have the potential to be affected, the wound nurse/designee completed an evaluation of current residents to identify new skin impairments. An audit of current pressure ulcers was completed to ensure they were measured weekly, treatments are appropriate, and care plan is updated. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated licensed staff on the requirements for F686. To monitor and maintain ongoing compliance, the DON/designee will audit pressure ulcer documentation weekly x4 then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.