Failure to Prevent and Assess Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent, identify, and properly assess skin conditions for two residents. For Resident #1, the facility did not implement preventative measures to minimize the development of pressure ulcers. The staff were aware that the resident preferred to stay in a certain position due to a device in use, but there was no documentation of the resident's refusal to offload his heels. The treatment to mitigate the pressure ulcers, including the use of skin prep, was initiated only after the first ulcer developed. For Resident #3, the facility failed to identify and properly assess a pressure ulcer on the resident's right foot prior to surveyor intervention. The wound care nurse (WCN) did not perform hygiene after removing a dirty dressing and before applying treatment, and the resident's tolerance to the treatment was not acknowledged. The WCN also failed to inspect the right foot, where an open wound was later discovered by the surveyor. The nurse had no knowledge of the wound, and the facility's documentation did not accurately reflect the resident's condition. The facility's failure to follow policies and procedures during treatment administration and to conduct thorough skin assessments resulted in the oversight of existing wounds. The Director of Nursing (DON) confirmed that a facility-wide skin sweep was conducted, but the right foot wound was still missed. The investigation determined that the facility did not adequately assess and document the residents' skin conditions, leading to deficiencies in care.
Plan Of Correction
N201: Right to Adequate and Appropriate Healthcare. 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. An order effective was created to provide off-loading; treatment to Resident #3. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Licensed Nursing staff will conduct weekly skin audits to monitor the residents for change in skin condition. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not reoccur. On, the Assisted Director of Nursing/designee initiated education on the components of the Failure to provide necessary care and services to prevent and promote healing of, with emphasis on providing treatment to ensure the healing of the. 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 with 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 to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance has been met.