Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent and promote the healing of pressure ulcers for one resident, resulting in worsening wounds. The resident, who was admitted with diagnoses including knee contractures, was observed without offloading boots, which were supposed to be on at all times as per the care plan. The boots were found on the floor, and staff members, including CNAs and a COTA, were unclear about their responsibility to ensure the boots were worn. Observations revealed pressure ulcers on the resident's left trochanter and coccyx, with the resident's feet resting directly on the mattress without pressure relief. The resident's care plan indicated the need for padded boots to be worn at all times, but this intervention was not consistently implemented. Interviews with staff, including CNAs, LPNs, and the wound nurse, revealed a lack of clarity and communication regarding the responsibility for ensuring the boots were worn. The wound nurse acknowledged that the resident's left foot wound was misidentified as a hematoma instead of a deep tissue injury, and the left trochanter wound was incorrectly documented as a blister rather than an unstageable pressure ulcer. The facility's failure to conduct a root cause analysis or hold care conferences to address the resident's pressure ulcers further contributed to the deficiency. The resident's coccyx pressure ulcer, initially documented as a stage 4, worsened over time, with increased drainage and slough covering the wound bed, rendering it unstageable. The Director of Nursing confirmed that the resident's care plan required the boots to be worn at all times, but this was not effectively communicated or enforced among the staff.
Plan Of Correction
Element 1 Resident 7 wounds were reviewed by the Director of Nursing, Wound Nurse, and wound care provider by 3/14/25, and it was determined reclassification of wounds was appropriate. The Coccyx Wound was reassessed on 3/13/25 by the wound care provider and determined that the wound needed to be reclassified again back to a stage 4 due to the resolving of slough in the wound bed from the previous week. Skin/Wound evaluations and care plans were updated to reflect the correct classification and staging of current wounds and include appropriate interventions to prevent and promote healing of wounds. Element 2 A one-time audit of current residents with wounds was completed to ensure the wounds are classified and staged correctly, and the care plans are updated and include appropriate interventions to prevent and promote healing of wounds. Any wounds not classified correctly were immediately reclassified and care plans updated. This was completed by the Director of Nursing/Designee by 3/14/25. Element 3 The QAPI Committee has reviewed the Pressure Ulcer Prevention and Management policy and has deemed it to be appropriate by 3/14/25. The Director of Nursing and/or designee educated the Wound Care Nurse and the licensed nurses on the Pressure Ulcer Prevention and Management policy by 3/14/25, with emphasis on correct classification and staging of wounds and ensuring that the care plans are updated and include appropriate interventions to prevent and promote healing of wounds. Nurse Aides were educated on checking resident kardexes and ensuring interventions are in place. This was completed by the Staff Development Coordinator/Designee by 3/14/25. Wounds will be reviewed weekly in the standard of care meeting to ensure wounds are classified and staged correctly, care plans are updated, and appropriate interventions are in place to prevent and promote wound healing. Element 4 The Director of Nursing/designee will audit residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure wounds are classified and staged correctly, care plans are updated, and interventions are in place to prevent and promote healing of wounds. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible to maintain compliance.