Failure to Provide Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards of practice for a resident with significant risk factors, including severe cognitive deficiency, impaired mobility, incontinence, and multiple comorbidities such as diabetes, heart failure, and kidney disease. The resident developed a pressure ulcer on the right buttocks, but there was inconsistent documentation and assessment of the wound. Weekly skin and wound assessments were either missing or incomplete, and there was no evidence of timely or thorough evaluation and documentation of the pressure ulcer's status, as required by facility policy and national guidelines. Orders for wound care and assessments were not consistently present in the resident's records, and documentation from the outside wound care company was not uploaded into the electronic medical health record as expected. Direct care observations revealed further deficiencies in wound management and infection control. During incontinence care, a CNA failed to sanitize hands before donning gloves and used soiled gloves to apply barrier cream directly to the resident's open coccyx wound, which was not covered with a dressing. The CNA acknowledged that this practice risked cross-contamination and infection and that open wounds should be reported to a nurse for appropriate treatment, not managed by CNAs. The resident was noted to have a strong odor of urine and a heavily soiled brief, indicating inadequate incontinence management, which is a known risk factor for pressure ulcer development and deterioration. Interviews with staff and the administrator confirmed that nurses were expected to complete and document weekly skin and wound assessments, notify the physician and responsible parties of changes, and administer wound treatments per orders. However, these expectations were not met, as evidenced by missing documentation, lack of timely notification, and improper wound care practices. The administrator also stated that CNAs should not apply treatments to pressure ulcers and should report skin issues to nurses, but this protocol was not followed in practice.