Failure to Provide Timely Wound Care Assessment
Penalty
Summary
The facility failed to provide the highest practicable care for a resident with a sacral ulcer. Resident 150 was admitted with a sacral ulcer, and an initial assessment was conducted with measurements recorded. However, on a subsequent date, staff found the resident's dressing missing and noted changes in the wound, including yellow slough and a slight odor. Despite these observations, there was a delay in reassessment by the registered nurse, assistant director of nursing/infection preventionist, who did not evaluate the wound until 3.75 days later. During this delayed assessment, the nurse observed further deterioration, including the presence of bone at the wound base and purulent drainage. The delay in timely assessment and intervention for Resident 150's sacral ulcer led to a failure in providing care in accordance with professional standards. The staff's initial observations of changes in the wound were not promptly addressed by the responsible nurse, resulting in a lack of timely updates to the resident's care plan. This deficiency was identified during a clinical record review and staff interview, highlighting the facility's failure to ensure timely and appropriate wound care management for the resident.
Plan Of Correction
Resident 150's wound continues to be assessed by Employee 1 during wound rounds. Staff present during clinical rounds on April 7, 2025, were educated on the action of the treatment ordered and assessing characteristics of an evaluation of wound odor only after the area is cleansed. The RN present during the dressing change to the wound on April 6, 2025, entered a late entry note with her assessment of the wound. The physician's assistant evaluated Resident 150's wound on 4/17/25 with Employee 1. New orders were received for testing and treatment of the sacral ulcer. Other residents with pressure injuries will continue to be evaluated by the wound nurse. Any concerns will be addressed with the provider. Any identified educational need from licensed nursing will be addressed by a Registered Nurse. Licensed nursing staff will be educated on evaluation of wound characteristics and expected outcomes with a debriding agent. Nursing staff will also be educated on notification of the RN present in the facility when a wound concern arises, assessment of the concern by the RN, and notification to the provider when the concern needs to be addressed. An audit of residents with pressure injuries will be completed weekly for 6 weeks to ensure that any concern for healing is evaluated by the Registered Nurse and addressed by the provider. Results of this audit will be reported to the Quality Assurance Committee.