Failure to Ensure Competency in Wound Care and Documentation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in caring for residents with pressure injuries, as evidenced by the care provided to two residents. For one resident with a history of left femur fracture, diabetes, and recent hip surgery, the treatment nurse did not perform or document weekly wound assessments as required by the facility's Wound Management and Prevention Policy. The nurse also failed to complete a change of condition assessment or notify the physician when the resident's left heel wound changed from a suspected deep tissue injury to an unstageable pressure injury. The medical record lacked accurate and timely documentation of the wound's progress, and the physician was not informed of the wound's decline, despite the presence of eschar, slough, and signs of infection. The resident's wound worsened, requiring further medical intervention and wound care consultation. Another resident, admitted with multiple diagnoses including metabolic encephalopathy and a history of stroke, developed a right buttock pressure injury that progressed from redness to moisture-associated skin damage, then to an unstageable injury, and ultimately to a stage four pressure injury. The Director of Nursing was not aware of this resident's pressure injury until it had reached stage four, and there was no evidence of clinical oversight or timely escalation of the wound's status. The care plan and treatment administration records indicated ongoing changes in the wound's condition, but the DON was not informed of these changes, and interventions such as increased repositioning and offloading were not implemented in a timely manner. Interviews with staff, including the treatment nurse and DON, confirmed that required wound assessments, documentation, and physician notifications were not completed according to facility policy. The DON acknowledged that wounds should be assessed upon admission, for any changes, and weekly, with all findings recorded in the resident's chart. The treatment nurse admitted to not documenting wound progress or notifying the physician of significant changes, and the DON confirmed a lack of oversight and monitoring for residents with pressure injuries. These failures resulted in a lack of accurate documentation and delayed care for both residents.