Failure to Provide and Document Pressure Ulcer Care per Physician Orders
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards and its own policies, resulting in the deterioration and infection of wounds for a resident. Staff did not consistently provide wound care as ordered by the physician, with multiple instances where wound treatments were not documented as completed on the Treatment Administration Record (TAR) for both the right heel and right gluteal fold wounds. There was also a lack of documentation explaining missed treatments, and the care plan was not updated to reflect the resident's actual skin breakdown and current wound treatments. The resident involved had significant risk factors, including a history of stroke with left-sided weakness, diabetes with circulatory complications, incontinence, and was admitted with a pressure ulcer. Despite these risks, staff failed to conduct timely and complete wound assessments, did not update the care plan to address new or worsening wounds, and did not ensure that wound care orders from the external wound care provider were entered and followed. The wound care provider's notes indicated periods of wound improvement and deterioration, with changes in wound size, drainage, and the presence of nonviable tissue, but these changes were not consistently addressed by facility staff. Interviews with facility staff, including CNAs, LPNs, the MDS Coordinator, the ADON, and the Administrator, revealed a lack of awareness and communication regarding the resident's wounds, inconsistent documentation practices, and failure to notify the wound care provider of new or worsening wounds. The resident ultimately developed an abscess with purulent drainage requiring hospital transfer and surgical intervention. Throughout the period reviewed, the facility did not maintain accurate and timely wound care records, did not follow physician orders, and did not update the care plan as required.