Failure to Provide Consistent Pressure Ulcer Care and Assessment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. For one resident admitted with a Stage IV pressure ulcer to the left trochanter, the facility did not conduct an initial wound assessment with a wound description and measurements upon admission. There was also a lack of documentation of wound assessments for both the stage IV hip and sacrum wounds for several days after admission. Additionally, daily wound care treatments were not consistently performed or documented according to physician orders, with multiple days where treatments were not signed off as completed. Staff interviews revealed confusion regarding responsibility for wound care, with some nurses believing the treatment nurse was responsible, while others thought the assigned nurse should complete the care in the absence of the treatment nurse. The Wound Care Physician was not notified of the stage IV wound upon admission, and the Director of Nursing was unaware that daily treatments were not being completed. Another resident with a Stage IV pressure ulcer to the sacrum and an unstageable ulcer to the right second toe did not consistently receive daily wound care treatments as ordered. The Treatment Administration Record showed multiple days where wound care was not documented as completed. Assignment sheets indicated that on these days, there was no assigned treatment nurse, and a Medication Aide was assigned to the resident with a nurse overseeing. However, both the Medication Aide and the overseeing nurse assumed the other was responsible for completing the wound care, resulting in missed treatments. The Wound Care Nurse, who was working part-time due to resignation, stated that floor nurses were responsible for wound care in her absence, but this was not consistently carried out. Both residents had significant medical histories, including severe cognitive impairment, malnutrition, and immobility, placing them at high risk for pressure ulcer development and complications. The lack of clear responsibility and communication among staff, as well as failure to follow physician orders for wound care, led to deficiencies in the care and monitoring of pressure ulcers. The Wound Care Specialist and Medical Director confirmed that wound care treatments were not completed as ordered, and the Director of Nursing was not aware of the lapses in care.