Failure to Update Wound Care Orders and Implement Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement and update physician orders, accurately assess and document pressure ulcers, ensure pressure ulcer prevention interventions were implemented, adequately assess and treat pain prior to wound care, and prevent the development of pressure ulcers for two residents. For one resident with severe cognitive impairment, muscle weakness, contractures, and a history of pressure-induced deep tissue injury, the facility did not update physician orders to reflect current wound care recommendations from an outside wound care provider. The resident's wound care was performed according to outdated orders, and the resident was observed without required pressure-relieving boots on multiple occasions. Pain was not assessed or treated prior to wound care, and as-needed pain medication was only administered after the procedure. Another resident, dependent on a wheelchair and with diagnoses including vascular dementia and diabetes, developed two facility-acquired stage II pressure ulcers. Documentation of the wounds was incomplete, lacking descriptions of the wound bed. The resident was repeatedly observed seated in a wheelchair without a pressure-relieving cushion, despite recommendations from a nurse practitioner for a specialty cushion and a low air loss mattress. Staff confirmed that the resident sometimes went weeks without a wheelchair cushion. The care plan did not reflect the presence of pressure ulcers or include interventions for pressure relief. Both cases demonstrate failures in following physician and wound care provider recommendations, maintaining accurate and updated documentation, implementing necessary pressure ulcer prevention and treatment interventions, and ensuring pain management during wound care. These deficiencies resulted in worsening of a pressure ulcer, unrelieved pain during wound care, and an increased risk of further skin breakdown for the affected residents.
Plan Of Correction
F686 - Treatment/Services to Prevent/Heal Pressure Ulcers Element #1 R11's Pressure ulcer was reassessed by the Wound NP. Wound measurements were updated, appropriate treatment orders were obtained, and pain management interventions were implemented prior to wound care. R20's new pressure ulcer was staged, documented, and entered into the treatment administration record. Physician orders were obtained and implemented. Preventive interventions were put in place. Element #2 The Director of Nursing and/or designee conducted a 100% audit of residents with existing pressure ulcers and residents at high risk for skin breakdown. The audit included verification of physician orders, review of treatment records, and assessment of pressure-relieving interventions. Pain assessments during wound care were also reviewed to identify any documentation or treatment gaps. Element #3 The Administrator reviewed the policy on Pressure Injury Prevention and revised as necessary. Licensed Nurses were provided education on timely and accurate wound assessment and staging, implementation and documentation of pressure ulcer prevention interventions, communication of wound care orders, and ensuring pain management is in place before treatment. Element #4 The Director of Nursing or designee will conduct weekly audits of all residents with pressure ulcers and those identified as high-risk (Braden score =18) for 12 weeks to ensure accurate documentation, orders, and treatment. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025