Failure to Follow Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when the facility failed to follow up on wound consultant recommendations for a resident with an unstageable pressure ulcer on the coccyx. The resident, who was bedfast most of the time and required maximum assistance for personal hygiene and bed mobility, had a care plan that included interventions such as a low air loss mattress, skin care protocols, and therapy consultations. However, the care plan did not address the resident's refusals to get out of bed or reposition, and there was no evidence that therapy or dietary consultations recommended by the wound consultant were initiated. The wound consultant had recommended ongoing treatments, optimization of nutrition, and a PT evaluation for support surfaces, but these recommendations were not communicated or acted upon by the therapy, dietary, or nursing staff. Observations showed the resident remained lying flat on their back throughout the day, and interviews with staff revealed that neither therapy nor the DNS were aware of the wound consultant's recommendations. The wound consultant confirmed that she expected therapy and dietary evaluations to have occurred, but was unaware that these had not been completed. Facility policy required rehabilitation screens for residents with significant changes in functional ability, but no such screen or evaluation was found for this resident following the new wound development.