Failure to Provide Pressure Ulcer Care and Prevent New Ulcers
Penalty
Summary
A resident with multiple comorbidities, including paraplegia, chronic kidney disease, and a history of pressure ulcers, was not provided with care and services in accordance with professional standards and physician orders to prevent new pressure ulcers and the worsening of existing ones. The resident was dependent on staff for bed mobility and had a care plan identifying the risk for skin impairment, with interventions for weekly wound monitoring, measurement, and physician notification of changes. However, there was no evidence that the care plan was updated to address a newly developed, facility-acquired pressure ulcer on the scrotum, nor was there documentation of physician notification or treatment orders for this new wound. There were significant lapses in wound care management, including a lack of wound care orders or treatment for the left ischium wound for nearly two months, and missed or incomplete documentation of weekly wound assessments, measurements, and wound descriptors for several pressure ulcers. The clinical record showed gaps in weekly wound assessments, with no evidence of assessments or measurements between certain dates, and missing documentation regarding the presence of tunneling in wounds. Additionally, wound care treatments for the right ischium and sacral wounds were not completed as ordered on multiple occasions, with no documentation of resident refusal or coordination of alternative care times as outlined in the care plan. Interviews with nursing staff and facility leadership confirmed awareness of the missed wound care treatments and assessments, as well as the lack of documentation and physician notification for the new scrotal pressure ulcer. Facility policies required prompt notification of changes in resident condition, systematic and comprehensive assessments, and completion of physician-ordered treatments, but these were not followed. The resident was later transferred to the hospital and treated for sepsis secondary to a sacral wound, with wound cultures positive for infection.