Failure to Provide Consistent Pressure Ulcer Care and Assessments
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers for a resident with significant risk factors, including complete paraplegia, muscle weakness, and a history of sepsis related to a sacral wound. The resident was admitted with a stage IV pressure ulcer to the sacrum and an unstageable pressure area on the left heel. Despite physician orders for specific wound care treatments and the need for weekly skin assessments, the facility did not complete weekly skin assessments or consistently provide ordered treatments to the resident's wounds over a period of several weeks. Documentation revealed that the resident did not receive wound care treatments as ordered on multiple occasions for both the sacral wound and the left heel. The treatment administration records showed missed treatments, and there was a lack of weekly skin assessments following the initial admission assessment. The wound care doctor was not made aware of the pressure area on the left heel, and the wound care nurse had left the facility, leaving gaps in wound care oversight. The resident's wounds worsened during this period, with the sacral wound increasing in size and the left heel developing into a full-thickness open wound with necrotic tissue. Interviews with staff confirmed that weekly skin assessments were not performed, and treatments were not administered as ordered. The resident reported not receiving care to the left heel and was unaware of the wound due to paralysis. The nurse responsible for documenting treatments admitted to mistakenly signing off on treatments that were not performed. Observations confirmed the presence of an old, dated dressing on the left heel and significant deterioration of the wound. Facility policies required regular skin assessments and documentation, which were not followed, leading to the identification of an Immediate Jeopardy situation.
Removal Plan
- Resident #1 received a head-to-toe assessment including skin by the DON, findings of a worsening left heel were relayed to Medical Director and new orders received to clean wound with normal saline, pat dry, apply alginate with silver and cover with non-adherent dressing daily.
- Findings were relayed to the Medical Director.
- Emotional Distress Assessment completed for Resident #1 by the Social Worker with no emotional distress observed.
- Resident #1's Care Plan was updated by Corporate MDS Nurse regarding wound care and observations to be performed by staff. All nursing staff were in-serviced including PRN, agency staff and all newly hired staff prior to their shift.
- Charge nurses on staff conducted a 100% skin audit on 78 residents overseen by the DON. Charge nurses were in-serviced on proper skin assessment by the DON prior to the conduction of assessments. No other residents were identified as having unidentified skin issues.
- Administrator/DON initiated Staff in-service for ALL NURSING STAFF on Prevention of Pressure Ulcers, Pressure Ulcers/Skin Breakdown - Clinical Protocol & Abuse and Neglect. DON trained by VP of Clinical Services prior to start of in-service. If staff are unable to attend any of the in-services, they will be required to complete them before starting their assigned shift to include PRN staff, agency staff and any new hires.
- The Medical Director has been involved in developing the Plan of Removal. These conversations are considered a part of the QA process.
- A QAPI meeting was held with attendance of the Company President, Director of Nursing & VP of Clinical Services.
- This plan will be monitored through completion by corporate staff.
- Plan of Removal completion with continuation of oncoming staff and follow up.