Failure to Administer and Document Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that residents at risk for pressure ulcers and those with existing pressure ulcers received necessary treatment and services consistent with professional standards of practice. Resident #68, who had a history of [DIAGNOSES REDACTED], was not provided with the required interventions to float their heels in bed, as documented in their care plan. Observations revealed that Resident #68's heels were directly on the mattress without any heel booties or pillows to float them, and there was no air mattress in place. Additionally, there was no documented evidence that skin prep treatments were administered as ordered on multiple occasions in February and March. Resident #352, who had [DIAGNOSES REDACTED], was also not provided with the necessary wound care treatments for their Stage 3 and Stage 4 pressure ulcers. The Treatment and Medication Administration Records showed no documented evidence that treatments were completed on several dates in May and June. Interviews with staff, including Licensed Practical Nurses and the Director of Nursing, confirmed that the treatments were not signed off, indicating they were not administered, and there was no documentation explaining the omissions. The facility's policy required daily monitoring and documentation of pressure ulcers and chronic wounds, but this was not adhered to for the residents in question. The lack of adherence to care plans and treatment orders, as well as the failure to document treatment administration, contributed to the deficiency in providing adequate care for residents with pressure ulcers.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - Resident #68’s heels were immediately floated and the attending physician was notified of the missed treatments. The resident’s care plan and treatment protocol was reviewed and revised to reflect the use of an air mattress. Resident #68 was monitored for 5 consecutive days with no issues noted. A medical record review was completed and no abnormal findings were identified. - Resident #352 was discharged from the facility on 7/2/2024. A medical record review was completed with no additional abnormal findings. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All Residents at risk for skin breakdown as per facility skin risk assessment have the potential to be affected. All residents identified as being at risk based on documented skin assessment were reviewed with no issues noted and care plan is in concert with the resident needs. No deficient practice noted. - ADON/designee completed an audit of all residents with skin breakdown to ensure all devices and treatments are in place and are being signed for by the licensed nurses. Element #3: The following system changes will be implemented to prevent reoccurrence: - The facility policy and procedure titled “Documentation of Pressure Ulcer and Chronic Wounds” was reviewed and found to be appropriate. - The staff educator/designee will provide education to all licensed nurses on documentation of pressure ulcers and chronic wounds policy; including closely monitoring the effectiveness of treatments, daily documentation of treatments provided, as well as documenting an explanation when a treatment is not completed. Additionally, education will be provided to all licensed nurses on updating the resident(s) care plan to accurately reflect interventions in place; such as floating heels and use of air mattress. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Nursing has created an audit tool to ensure that all residents with pressure ulcers/chronic wounds have proper treatment orders in place that are signed for by licensed nurses and that proper interventions are in place. - Unit managers/designee will audit once a week until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected and reported to the Director of Nursing. - Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after 4 weeks of 100% compliance. Element #5: The person responsible for the corrective actions is the Director of Nursing/designee. Date of compliance is 4/18/25.