Failure to Follow Pressure Ulcer Care Protocols and Implement Wound Treatments
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. For one resident with bilateral heel pressure ulcers, staff did not consistently follow physician orders and wound care recommendations to off-load the heels using protective booties while in bed. Multiple observations showed the resident's heels resting directly on the mattress without the prescribed booties, despite clear orders and recommendations from the wound physician to off-load the wounds and use heel-relieving devices. The resident was also noted to have significant pain in one heel during these observations. For another resident who was re-admitted with a lower back pressure wound, the facility did not implement the recommended wound treatment as outlined in the hospital discharge summary. The resident's records lacked a physician order for wound care, and the Treatment Administration Record (TAR) did not reflect any wound treatment being provided. The plan of care also failed to include wound care interventions. Nursing staff acknowledged that the wound order was missed and not entered until several days after re-admission, despite being aware of the open area. Interviews with nursing staff and the DON confirmed that wound care recommendations and documentation protocols were not followed as required by facility policy. Staff stated that new wounds should be measured, documented, and reported to the physician, with appropriate treatment orders implemented, but these steps were not consistently carried out for the affected residents.