Failure to Provide Timely Pressure Ulcer Care and Update Care Plan
Penalty
Summary
A resident with multiple comorbidities, including type 2 diabetes, dementia, and chronic kidney disease, was identified as being at risk for pressure ulcers. Despite this, when an open area was first noted on the resident's coccyx, there was no documented evidence of a wound assessment or progress note on the day of discovery. Treatment for the pressure ulcer was not initiated until several days later, and the care plan was not updated to reflect the new wound, its treatment, or additional interventions. The only intervention documented in the care plan was the use of a pressure-reducing cushion in the wheelchair, with no mention of turning, positioning, or wound care measures. The facility's policies required daily skin inspections, prompt evaluation and documentation of skin changes, and weekly wound assessments by the wound care team. However, there was no evidence of weekly wound assessments for the resident between the initial wound care team assessment and the resident's subsequent decline. Interviews with staff revealed confusion regarding responsibilities for skin checks, wound documentation, and care plan updates, particularly during a transition between electronic medical record systems. Staff also reported that care plan changes were not automatically reflected in care cards used by certified nurse aides, leading to gaps in communication and implementation of interventions. The resident's condition deteriorated, with the wound progressing to an unstageable ulcer with necrotic tissue and signs of infection. The resident became minimally responsive and was ultimately transferred to the hospital, where they were diagnosed with sepsis. Throughout the period in question, there was a lack of timely documentation, delayed initiation of treatment, and failure to update the care plan and implement recommended interventions, all of which contributed to the deficiency cited in the report.