Failure to Provide Timely Pressure Ulcer and Vascular Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident at risk for developing pressure ulcers and complications, as required by facility policy, the care plan, and physician orders. Licensed staff did not ensure timely referral and follow-up for the resident's appointments with a vascular physician and a wound specialist, despite recommendations and orders from the nurse practitioner. The resident was not evaluated by a vascular physician until several months after the initial recommendation, and the wound specialist referral was delayed by 19 days after the order was given. These delays were compounded by a lack of documented attempts to seek alternative providers or escalate the issue when scheduling difficulties arose. The resident had a complex medical history, including diabetes mellitus, chronic kidney disease, end-stage renal disease on hemodialysis, and peripheral vascular disease (PVD). The resident was identified as being at moderate risk for pressure injuries, with multiple care plans and assessments documenting the presence and progression of pressure ulcers and ischemic wounds on the lower extremities. Despite these risk factors and documented changes in the resident's skin condition, there were lapses in wound assessment documentation, failure to measure and stage wounds consistently, and inadequate communication with the physician regarding changes in the resident's condition. Interviews with facility staff revealed that verbal orders for specialty referrals were not always documented or acted upon, and there was confusion regarding responsibility for follow-up. The director of nursing acknowledged that no alternative arrangements were made when the primary referral system was unavailable, and there was no comprehensive care plan developed for the resident's PVD or related complications after significant diagnostic findings. As a result of these deficiencies, the resident experienced delays in wound assessment and intervention, leading to worsening gangrene, infection, and ultimately transfer to an acute care hospital, where the resident was later discharged to hospice and subsequently passed away.