Failure to Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to properly assess, monitor, and treat a skin impairment for a resident, leading to a deficiency in care. The resident, who had a history of diabetes and peripheral vascular disease, was found to have an unstageable pressure ulcer on the left heel during wound rounds. The facility's policy required timely assessment and documentation of pressure sores, but the resident's clinical record did not reflect any skin impairments aside from an existing issue on the right hip until the wound team discovered the new ulcer. The nursing progress notes and facility investigation revealed that the dressing on the resident's left heel was not dated or initialed, making it unclear how long it had been in place. The wound nurse practitioner noted that the ulcer was covered with 80% slough and required surgical debridement. The facility's investigation could not determine who applied the dressing, but it was noted that only nurses had access to the treatment cart where the dressing supplies were kept. Interviews with staff, including the Director of Nursing, confirmed that the resident's left foot was already compromised due to medical conditions and a right leg amputation. The Director of Nursing acknowledged that the wound should have been assessed and treated promptly. The failure to do so resulted in the development of an advanced unstageable pressure ulcer, necessitating surgical intervention.
Plan Of Correction
1. Resident R39 wound dressing is dated and physician orders for the wound treatment are being followed. 2. Current residents with wound dressings have been reviewed by the DON or designee to ensure treatments are dated and physician orders for the treatment are in place. 3. Licensed staff will be educated by the DON or designee on wound treatment dressings which cannot be applied on a skin impairment without physician orders. If a skin impairment is identified, the physician will be notified and wound treatment orders will be obtained. 4. Random audits of residents with wound dressings will be completed by the DON or designee weekly x4 to ensure wound dressings are dated and physician orders are followed. The audits will be reported to QAPI committee and the QAPI committee will determine the need for further audits.