Failure to Provide Timely Pressure Ulcer Care on Admission
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate pressure ulcer care and prevent the development of a new unstageable pressure ulcer for one resident at risk. Upon admission, the resident, an 89-year-old female with multiple comorbidities including pulmonary hypertension, chronic kidney disease, venous insufficiency, diabetes, and a history of myocardial infarction, was noted to have a skin alteration described as an abrasion or erythema on the thoracic spine. The initial assessment documented the presence of a wound, but no specific wound care interventions or treatment orders were initiated at that time. The resident's Braden score indicated a high risk for pressure sore development, and the care plan identified the potential for pressure ulcer development, but interventions were not implemented as required. Between the resident's admission and several days afterward, there was a lack of wound care treatment and preventive interventions. The wound was not properly monitored or reassessed, and no weekly skin/pressure ulcer assessment was documented until several days after admission. The wound subsequently progressed to an unstageable pressure ulcer, as confirmed by a wound care physician who performed debridement and described the wound as having slough and devitalized tissue. The physician and wound care nurse both indicated that the wound was not properly identified or managed upon admission, and the charge nurse responsible for the admission acknowledged an oversight in not initiating orders or monitoring the wound, citing insufficient education on admission expectations for skin concerns. Interviews with facility staff, including the DON and wound care physician, confirmed that the wound was mischaracterized at admission and that the required steps for assessment, documentation, and intervention were not followed. The facility's policies required a thorough skin check and immediate initiation of a wound flow sheet and treatment orders when a wound is identified, but these procedures were not adhered to. This failure placed the resident at risk for the development and worsening of a pressure ulcer, resulting in the identification of an Immediate Jeopardy situation by surveyors.
Removal Plan
- One on one in service with LVN Charge Nurse to review admission Skin Assessment/ Documentation Treatments and Notification. Overview of Resident #1 and education on expectations of interventions, notification, and documentation. LVNs knowledge and effectiveness of training by conducting quiz, chart audit and feedback given with results of audit, will continue training. LVN received counseling for insufficient assessment and documentation.
- Resident #1's head-to-toe skin assessment completed. Initiated medication review by Medical Provider, Wound Care Provider review of treatment orders for appropriateness. Social Service Assessment conducted to ensure psychosocial well-being. No mental anguish or psychological distress related to delay in treatment, notification of findings communicated to medical provider and Resident #1.
- In service provided to Administrator and DON by Clinical Resource on New Admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions. In serviced on following up on new admission with chart audits and continue education and counseling as needed by Clinical Resource.
- 100% Charge Nurse In-Service for New Admission Skin Assessment/ Documentation Treatments and Notification. PRN nurses in serviced. We do not utilize agency staff. New staff will be in serviced upon hire. Nurses will not work floor until in serviced.
- Nurse Management in service for New Admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions.
- Admissions, MDS, DOR, ADOR, Treatment Nurse, ADON informed of IJ, and template reviewed.
- Medical Director notified of IJ. Medical Director involved in development of plan and in agreement.
- An Ad hoc QA meeting will be completed. Attendees will include ED, DON, ADON, Clinical Resource, and Medical Director. Meeting will include the Plan of Removal and interventions.
- Audit on current residents with pressure ulcers.
- Audit on new admissions without Treatment Nurse Assessment. New admission Treatment Nurse Assessments are in place, Treatment in place when appropriate.
- Skin sweep on with residents with wounds and new admissions. Resulted in no new finding.
- RCA/QIT with IDT and Medical Director. IDT meet to discuss initial admission skin assessments that identify skin issues without treatment orders being placed initially by charge nurse and then a delay in treatment. This was often found on Friday admissions, where the treatment nurse did not see patients until the following week. All nurses being in-serviced prior to working their next shift on Admission skin assessment process, implementing orders and interventions and documentation. Treatment nurse was only assessing patient's that it was communicated had wounds. Treatment nurse or designee is to complete a skin assessment on all admissions on next working day to ensure accurate assessment and treatments are appropriate.
- Treatment Nurse, Admissions Nurse and MDS Resource to conduct in service to nurses trained on New Admission Skin Assessment/ Documentation Treatments and Notification and expectation.
- DON or designee to verify nurse knowledge on New Admission Skin Assessment/ Documentation Treatments and Notification by quizzing 5 nurses weekly and ongoing for nurse new hires
- Summary of IJ and corrective action to be reviewed by QAPI Committee monthly or until substantial compliance established.
- Care Plan audit for all residents with pressure/skin alterations. Care Plans update for appropriate interventions.
- Audit new Admissions for initial skin assessment and treatment nurse assessment, ensuring interventions and orders in place.