Failure to Prevent and Manage Pressure Ulcers and Inadequate Wound Care Monitoring
Penalty
Summary
The facility failed to prevent the development of avoidable pressure ulcers and did not provide adequate monitoring, treatment, and care for existing pressure ulcers in three residents. One resident, who was re-admitted with multiple risk factors such as Multiple Sclerosis, immobility, and incontinence, had no pressure ulcers upon admission but developed two Stage 3 pressure ulcers during their stay. The care plan for this resident did not address their risk for pressure ulcers, and there was no evidence of timely provider notification or implementation of interventions when skin issues were first identified. Weekly skin assessments and wound monitoring were inconsistently documented, and wound care orders were not always followed as prescribed. Another resident was admitted with a Stage 3 pressure ulcer on the sacrum. The care plan included interventions for wound care and monitoring, but there was no evidence that wound progress was assessed or documented as required. Wound care orders were not completed on several occasions, and weekly skin assessments were either incomplete or missing, with no documentation of wound measurements or changes in wound status. The root cause of additional wounds was not identified, and interventions for these areas were not implemented. A third resident with a history of immobility, incontinence, and a Stage 4 sacral pressure ulcer did not consistently receive prescribed nutritional supplements intended to support wound healing due to unavailability of the product. The supplement was not administered on multiple occasions across several months, and the provider was not notified of the ongoing unavailability in a timely manner. Additionally, wound care documentation revealed lapses in wound vac functioning and the presence of fecal contamination in the wound area, with no evidence of prompt intervention or provider notification.