Failure to Assess and Implement Pressure Ulcer Care and Offloading Interventions
Penalty
Summary
The facility failed to assess and implement timely treatment interventions for pressure wounds and did not ensure that pressure-relieving interventions were in place for three residents with pressure wounds. For one resident, although the admission and after-hospital care plan indicated a sacral pressure wound and ordered zinc paste treatment, there was no evidence of treatment initiation or wound care orders for the sacrum documented in the treatment administration record or order summary report. Another resident had multiple pressure wounds identified on admission, including to the groin, sacrum, and both posterior thighs, with specific wound care orders from the hospital. However, no wound treatment orders were transcribed, and no treatments were initiated for the thigh wounds until six days after admission. Additionally, the groin and sacrum wounds were not addressed in the treatment administration record, and wound care nurse assessments for these residents were not available prior to a specific date. A third resident was observed with a wound vacuum on the left heel and a pressure reduction boot only on the right foot, despite orders and care plans specifying that both heels should be offloaded and protective boots should be used when in bed. Observations showed the left heel resting directly on the bed without a boot, and the resident was unaware of why only one boot was applied. Staff interviews confirmed that standard care requires offloading both heels, and if boots are not available, alternative methods such as pillows or wedges should be used. Facility policies required prompt transcription of physician orders and full skin assessments, which were not followed in these cases.