Failure to Implement and Document Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Multiple residents, including those with severe cognitive impairment and total dependence on staff for activities of daily living, did not have wound consultant recommendations implemented in a timely manner, or at all. For example, one resident with a stage 4 left heel pressure ulcer did not receive the updated treatment recommended by the wound consultant for nearly a month after the wound was debrided and restaged. The treatment administration records continued to reflect the previous regimen, and the new orders were not entered or implemented until much later, despite clear communication from the wound consultant and expectations from the medical director and nurse practitioner that recommendations be followed. In several cases, documentation was incomplete or missing, with treatment administration records left blank on multiple days without corresponding progress notes or evidence that treatments were refused. For one resident, eight wound treatments were not documented as provided in a single month, and there was no supporting documentation to indicate whether the treatments were completed or refused. Interviews with nursing staff and the DON confirmed that blank records meant there was no evidence the treatments were done, and that staff were unclear about their responsibilities for entering and implementing wound care orders. Other residents with pressure injuries, including those with new or worsening wounds, did not have wound consultant recommendations such as specific dressing changes, offloading, repositioning, or nutritional supplements implemented or documented in the medical record. In some cases, recommendations for supplements like zinc were delayed for months, and care plans were not updated to reflect actual skin breakdown or new interventions. Observations confirmed that residents were without ordered treatments or offloading measures, and staff were unaware of current wound care needs or orders. The failure to implement and document wound care recommendations was consistent across multiple residents and over extended periods.