Failure to Provide Necessary Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcers for two residents, R4 and R5, consistent with professional standards of practice. Resident R4, who had diagnoses including heart failure, arthritis, and cancer, was admitted to the facility and later developed a new Stage 2 pressure injury on the right buttock. Despite a wound care nurse practitioner's order for specific treatments and protein supplements to promote healing, these orders were not entered into the electronic medical record, and the Treatment Administration Record (TAR) did not document that the resident received the prescribed treatment. Similarly, Resident R5, who had diagnoses of diabetes and osteomyelitis, developed a new Stage 2 pressure injury on the right lower leg. The wound care nurse practitioner ordered specific treatments and protein supplements for this resident as well. However, the physician's orders and the TAR did not reflect these orders, and there was no documentation that the resident received the necessary treatment. Interviews with the Assistant Director of Nursing, the Nursing Home Administrator, and the Director of Nursing confirmed the facility's failure to ensure that residents received the required care for pressure ulcers. The facility's policy required the physician to order pertinent wound treatments, but this was not adhered to, resulting in a lack of appropriate care for the residents' pressure injuries.
Plan Of Correction
Resident 4 was immediately reviewed to ensure physician orders were entered correctly and wound care was immediately initiated, and all missed treatments were assessed and caught up as appropriate. A skin care note and wound progress documentation were entered retrospectively based on the wound nurse's findings. Resident's care plan was reviewed to ensure accuracy. Resident 5 was immediately reviewed to ensure physician orders were entered correctly and wound care was immediately initiated, and all missed treatments were assessed and caught up as appropriate. A skin care note and wound progress documentation were entered retrospectively based on the wound nurse's findings. Resident's care plan was reviewed to ensure accuracy. DON conducted facility-wide skin audit on all wound treatment orders to ensure timeliness of wound identification and documentation, presence of treatment orders in the EMR, accuracy of TARs and completion records. House skin sweep conducted to ensure all residents assessed for wounds and ensure treatments are completed per order. No harm was identified in any of these cases. Mandatory in-service training will be held by DON for all licensed nursing staff and wound care coordinators by 4/30/25 on wound care policies and procedures, proper and timely EMR documentation of new wounds and associated orders, TAR compliance expectations and treatment completion per physician order. DON/designee will audit all new wound treatment orders to ensure that treatments are being delivered and documented 5 days per week for 4 weeks, then 3 times per week for 2 weeks.