Failure to Provide Timely and Adequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care for optimal skin condition of a pressure wound in accordance with professional standards. The care plan for the resident did not include specific interventions to prevent the development or worsening of pressure ulcers, such as repositioning, offloading, or encouraging the resident to get out of bed. Documentation was inconsistent, with missing or incomplete records regarding wound assessments, measurements, and the implementation of physician-ordered treatments. There was also a lack of timely updates to the care plan when new wounds developed or when interventions were initiated, such as the use of specialty mattresses or pillows for pressure relief. The resident, who had multiple diagnoses including acute kidney failure, prostate cancer, and severe cognitive impairment, was at moderate risk for pressure ulcers according to the Braden Scale. Upon admission, there were no skin issues noted, but over time, the resident developed pressure injuries to the sacrum and buttocks. The facility did not consistently document wound care, assessments, or the application of prescribed treatments. There were delays in implementing recommended interventions, such as the use of a low air loss mattress, and the care plan did not reflect changes in the resident's condition or the need for additional interventions as wounds worsened. Interviews with facility leadership revealed gaps in communication, documentation, and wound care management. The DON acknowledged that care plans did not include necessary interventions or documentation of refusals, and that weekly skin assessments were not completed as required. The facility lacked a wound care certified nurse, and there was uncertainty about whether the resident's physician was kept informed of wound status changes. The resident's wounds deteriorated during the stay, and the facility did not ensure timely or adequate assessment, intervention, or care planning in accordance with professional standards.