Failure to Assess, Monitor, and Treat Wounds per Orders and Policy
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring for residents at risk for skin impairment, resulting in missed identification and documentation of new wounds, lack of timely physician notification, and failure to update care plans and notify family members. In one case, a resident with multiple comorbidities and high risk for skin breakdown developed new wounds that were not promptly addressed in the care plan, and the family was not informed of these changes. The wound care coordinator acknowledged that the care plan should have been updated and the family notified, but these actions were not taken at the time of the deficiency. There were also failures to follow physician orders for wound care treatments. For example, a resident with a stage 4 sacral pressure ulcer did not receive the correct type of dressing as ordered, with staff using gauze instead of foam dressings. Another resident with multiple wounds received foam dressings instead of the ordered gauze dressings, and a CNA failed to use proper PPE during wound care. These deviations from prescribed wound care protocols were confirmed by staff interviews and direct observation. Additionally, the facility did not adhere to manufacturer recommendations for the use of low air loss mattresses, as multiple layers of linen and blankets were placed between the resident and the mattress, contrary to guidelines. There were also lapses in medication management, such as wound care medications not being available on the treatment cart, use of another resident's medication, and leaving the treatment cart unlocked. New skin impairments were not reported to the nurse, and wound care documentation was incomplete or missing. These deficiencies affected all four residents reviewed for pressure ulcer and wound prevention and treatment management.