Failure to Prevent and Manage Pressure Ulcers and Notify Physician
Penalty
Summary
The facility failed to maintain an effective skin management program to prevent the development and worsening of pressure injuries. Specifically, wound assessments were not completed as required for two residents, with missing documentation on wound location, stage, size, characteristics, periwound, and wound edge descriptions. Additionally, the facility did not follow its own policy regarding wound photographs and measurements for three residents. There was also a failure to contact the physician prior to initiating a wound treatment order for one resident, and the required SBAR communication tool was not completed when new or worsening wounds were observed. Notification of the physician and family was not performed for three residents experiencing changes in wound status. One resident's pressure ulcer deteriorated, developing drainage and a foul odor, which ultimately required emergency surgery and resulted in a diagnosis of sepsis. Treatment orders were not followed for two residents, further contributing to the deficiencies. The sample size for the review was four residents, with a facility census of 151 at the time of the survey. The facility's policies outlined clear procedures for wound assessment, documentation, and communication, including weekly wound rounds, use of the Braden Scale for risk assessment, and specific documentation requirements for wound characteristics and interventions. Despite these policies, the facility did not adhere to the established protocols, resulting in delayed or incomplete assessments, lack of timely physician notification, and failure to implement or document appropriate interventions for residents with pressure injuries.