Failure to Provide Proper Pressure Ulcer Care and Infection Control
Penalty
Summary
Facility staff failed to provide appropriate care and prevention for pressure ulcers, resulting in deficiencies in both the management of existing wounds and the prevention of new ulcers. For one resident with a history of peripheral vascular disease, diabetes, and prior toe amputation, staff did not adequately address the need for an appropriately sized bed, despite repeated reports from the resident, CNAs, and therapy staff that the resident was too tall for the bed and frequently slid down, causing the toes to press against the foot board. Multiple interventions, such as wedges and heel protectors, were attempted but were ineffective, and documentation shows that the resident's need for a longer bed was not addressed in a timely manner. The resident developed a pressure ulcer on the right great toe, which worsened over time and eventually became infected with MRSA, leading to hospitalization and amputation. Additionally, staff failed to follow up with the physician in a timely manner regarding a wound culture for the same resident. After a wound culture was obtained due to signs of infection and stalled healing, preliminary results indicating a staph infection were available, but there was a delay in notifying the physician and initiating appropriate antibiotic therapy. Documentation gaps were noted, including missing records of daily dressing changes and unclear communication between nursing staff and the nurse practitioner regarding the wound culture results and subsequent care. For another resident with a history of chronic pressure ulcers and osteomyelitis, staff failed to utilize appropriate hand hygiene prior to and during pressure ulcer wound care. Facility policy requires hand hygiene before and after patient contact, before donning gloves, and after glove removal, but observations revealed that these protocols were not consistently followed. This lapse in infection control practices further contributed to the facility's failure to provide care in accordance with professional standards and facility policy.