Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to follow a nurse practitioner's order to consult a wound care doctor for a newly acquired wound and did not implement appropriate pressure ulcer prevention and care for two residents. One resident, who had multiple significant medical diagnoses including encephalopathy, end stage renal disease, and dementia, was identified as high risk for pressure ulcers and required substantial assistance for repositioning. Upon readmission, redness was noted on the resident's buttocks and heels, but the heel assessment was not documented, and only the buttocks redness was communicated to the next shift. When an open area was later found, the nurse notified the doctor via a messaging system but did not enter any orders or document the wound in wound rounds. The nurse practitioner's directive to consult wound care was not entered into the system, resulting in no treatment or wound care consult being provided. The resident's care plan lacked any skin or wound care interventions, and the resident was not listed among those with facility-acquired wounds, despite clear evidence of wound progression and subsequent hospitalization for sepsis and pressure wounds. Another resident, with diagnoses including rhabdomyolysis and chronic kidney disease, was also at risk for pressure ulcers and required maximal assistance for repositioning. This resident developed a coccyx ulcer, which was first identified by a wound doctor over a month after it appeared on the facility's wound list. Observations showed the resident remained in the same position for extended periods, contrary to the facility's policy requiring repositioning every two hours for bedbound residents. Staff stated the resident was kept on her right side to avoid pressure on the coccyx ulcer, but there was no evidence of regular repositioning or a care plan addressing skin or wound care. Both residents lacked individualized care plans for skin or wound care, and the facility did not follow its own wound management and repositioning policies. The failures included lack of documentation, communication, and follow-through on provider orders, as well as absence of preventive and treatment interventions for residents at risk for or experiencing pressure ulcers.