Failure to Notify Provider of Worsening Pressure Ulcer Resulting in Hospitalization
Penalty
Summary
A resident with a history of peripheral vascular disease, renal insufficiency, diabetes mellitus, paraplegia, and malnutrition was identified as being at risk for pressure ulcers and was dependent on staff for transfers and mobility. Upon readmission from the hospital, the resident had an unstageable pressure ulcer on the left buttock. The care plan required weekly and as-needed wound assessments, documentation of wound status, and prompt reporting of any improvements or declines to the medical provider. Despite these requirements, documentation showed that the pressure ulcer worsened over several weeks, with increasing size, slough, and eventually eschar formation, as well as the development of foul odor and drainage. Throughout the period of documented wound deterioration, there was a consistent lack of evidence that the facility notified the medical provider of the worsening condition. Weekly wound documentation repeatedly noted the wound was 'worse,' but there was no corresponding documentation of provider notification or intervention. Staff interviews confirmed that the wound nurse relied on other staff to report changes, and the DON was unaware of any direct communication with the wound clinic or higher-level expertise during the period of decline. The resident was only referred to the wound clinic after significant deterioration had occurred, and the wound continued to worsen until the resident required hospitalization for a complicated wound infection and sepsis. Facility policy required notification of the provider for new pressure injuries, lack of healing, or complications such as infection. The clinical record review revealed that these requirements were not met, as there was no documentation of provider notification during multiple episodes of wound decline and complication. The failure to intervene and inform the provider of the worsening pressure ulcer ultimately resulted in the resident's hospitalization for advanced wound care and infection management.