Failure to Provide Comprehensive Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to monitor and complete comprehensive skin assessments, evaluate the effectiveness of interventions, and provide physician-ordered treatments as prescribed for a resident at risk for pressure ulcers with a history of such ulcers. The resident, who was obese, dependent on staff for lower body care, had an indwelling urinary catheter, and was always incontinent of bowels, was identified as having a healed stage III pressure ulcer and a moderate risk for pressure ulcers according to the Braden scale. The care plan included interventions for behavior management and pressure ulcer prevention, but the resident frequently refused care and preferred to sleep in a recliner rather than a bed. Between early March and early April, the treatment administration record indicated that a prescribed mixture of calmoseptime ointment and collagen fibers was applied to the resident's buttocks twice daily. However, there was no corresponding documentation of skin assessments or monitoring of the treated area during this period. During an observed care episode, staff did not follow the physician's order to mix the cream with collagen, nor did they measure or assess the affected areas. The nurse present was not comfortable with wound staging and deferred to the DON for assessment, and staff reported that the resident's behaviors often led to rushed care and missed steps. Interviews with staff revealed inconsistent wound care practices, lack of proper documentation, and uncertainty regarding wound assessment and treatment. The infection preventionist and DON confirmed that the current wound treatment was not appropriate and that staff were expected to document wound conditions daily and seek guidance if unsure. Facility protocols required verification of physician orders and documentation of wound care and assessments, but these were not consistently followed, resulting in a failure to prevent new ulcers and properly manage existing skin breakdown.