Failure to Accurately Assess, Monitor, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to follow policies and procedures to accurately assess, monitor, and treat pressure ulcers for two residents. For one resident, the initial skin assessment upon admission documented only a stage 1 ulcer on the gluteal cleft, with no mention of other skin issues. However, subsequent assessments revealed a stage 3 pressure ulcer on the coccyx and multiple open, weeping areas on the buttocks and inner thighs. The resident was observed to be left in the same position for extended periods, was not on a turning schedule despite being unable to reposition herself, and experienced prolonged exposure to moisture and soiled briefs. Staff were unaware of or did not follow a turning schedule, and there was a lack of timely wound care orders and documentation for the identified wounds. The DON could not provide consistent or complete documentation of the resident's wounds or treatments, and excoriated areas were not measured or tracked for improvement or decline. For another resident with a history of a stage III/IV sacral pressure ulcer and high risk for pressure ulcers, deficiencies were observed in wound care practices and documentation. During a dressing change, an LPN failed to use a barrier or clean the table for wound care supplies, did not change gloves or perform hand hygiene between removing the old dressing and applying the new one, and packed the wound with a soiled glove. The resident's brief was saturated with urine and not cleaned prior to the dressing change. There was also a lack of clear documentation of wound care visits and assessments in the medical record, and the care plan did not include meaningful interventions or revisions for the resident's stage III/IV pressure ulcer, such as frequent repositioning or offloading. Interviews with staff revealed inconsistent knowledge and application of infection control and wound care protocols, including hand hygiene, glove changes, and proper handling of wound care supplies. The facility's own policies required full body skin assessments upon admission and weekly, clear documentation of pressure injuries, and clean technique for dressing changes, including cleaning the work surface and changing gloves. These policies were not consistently followed, leading to deficiencies in the prevention, assessment, and treatment of pressure ulcers for the affected residents.
Plan Of Correction
1. Resident #350 no longer resides at facility. The nurse was instructed to complete a wound assessment but failed to do so. This nurse was coached by DON. Resident #1 still currently resides in the facility; no negative outcome was identified due to this deficient practice. Her plan of care has been reviewed to reflect her status. She was assessed and is comfortable. Her wound care documentation is up to date. 2. Like residents are identified as those with pressure injuries. The plans of care for all like residents were reviewed by 4/25/2025 and updated to reflect the residents' current needs and treatment. 3. The policy and procedure on skin management, along with dressing change policies, have been reviewed and revised. Consultant Nurse educated the DON on assessments and documentation on skin management. Nurses were educated by DON/designee by 4/25/2025 on appropriate management/documentation/care. An admission wound assessment was activated in the EMR. Licensed Nursing staff were educated on completing this assessment on admission. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents currently in the facility with wound injuries to ensure their wounds are properly cared for and documented, and their plan of care/orders addresses their needs. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.