Failure to Implement Timely Wound Care Orders and Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to implement appropriate measures for the care and management of an unstageable sacral wound in a resident with multiple comorbidities and a rapidly declining condition. The wound was first observed by a Certified Nurse Aide and a Licensed Practical Nurse, but neither notified the Nurse Practitioner or physician to obtain treatment orders at the time of discovery. The LPN cleansed the area and applied a dry border gauze dressing without obtaining proper medical orders or updating the care plan. Documentation shows that there was no treatment administration record or physician orders for wound care for the month in which the wound was identified, and the care plan was not updated until several days later. Interviews with facility staff, including the Wound Care Nurse, Director of Nursing, and Administrator, confirmed that the expected protocol was not followed. The facility's own policies require prompt notification of a health care provider and updating of care plans when a new wound or change in skin condition is identified. The resident was at moderate risk for skin impairment and had diagnoses including encephalopathy, dysphagia, dementia, and atrial fibrillation. The lack of timely notification, absence of treatment orders, and failure to update the care plan directly contributed to the deficiency in pressure ulcer care and prevention.