Failure to Provide Consistent Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents. In the first case, a resident with a moisture-related skin injury was admitted and later returned from the hospital with a stage 2 pressure injury. Although the wound care team recommended treatment with a specific cream every shift, there was no evidence that this treatment or any alternative was implemented prior to a formal order being placed, and administration of the cream was not documented before that date. The DON confirmed that the wound care recommendations were not followed. In the second case, a resident with a history of cancer, depression, and a burn injury was admitted with three unstageable pressure ulcers and was identified as being at risk for further skin breakdown. Multiple wound care orders were documented, but several treatments were missed according to the medication and treatment administration records. There was also a lack of documentation confirming that all steps of the wound care process, such as cleaning and dressing the wounds, were completed. The DON acknowledged that the records indicated missed treatments and could not provide evidence that the required care was given. The third case involved a resident with an identified alteration in skin integrity at the sacrum. The care plan included daily wound care, but the treatment administration record showed that wound care was not documented on several days. The unit manager confirmed that care was not provided on those dates and no additional evidence was available. The deficiency was discussed with the Nursing Home Administrator, and no further documentation was provided.