Delayed Wound Care Referral for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services consistent with professional standards of practice. Upon readmission, the resident had a sacral pressure ulcer, but the facility did not refer her to the wound care consultant as required by their wound care management protocol. The referral to the wound care consultant was delayed, occurring several days after the resident's readmission, despite the presence of a significant wound. The resident in question was an elderly female with multiple medical conditions, including a cervical vertebrae fracture, spinal fusion, osteoporosis with pathological fractures, and severe protein-calorie malnutrition. She was cognitively intact but required substantial to maximum assistance with activities of daily living and was always incontinent of bowel and urine. Upon readmission, she had a stage III pressure ulcer and a surgical wound, and was at high risk for further skin breakdown. Documentation showed that wound care orders and pressure-relieving devices were in place, but the required wound care consult was not initiated until several days after admission. Interviews and record reviews revealed that the delay in referral was due to a lapse in following the facility's protocol, compounded by the sudden resignation of the treatment nurse responsible for wound care management. Staff assumed the referral had been made, but it was later discovered that consent for the wound care consult had not been obtained and the referral had not been completed. The resident's family expressed concerns about the effectiveness of the wound care and the functionality of the pressure mattress, and the wound care physician confirmed that the consult was not received until after the delay.