Failure to Provide Ordered Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with multiple diagnoses, including adult failure to thrive, chronic kidney disease, and sequelae of cerebral infarction, was admitted to the facility and assessed as being at risk for pressure-related skin impairment due to factors such as shear friction and bed confinement. The care plan included interventions like keeping the resident clean and dry, providing peri care after incontinence, and weekly skin checks by a licensed nurse. Despite these measures, a Stage III pressure injury was identified on the resident's coccyx during a post-shower skin check, which had not been previously observed. Following the identification of the pressure injury, physician orders were written for specific wound care treatments, including cleansing with normal saline, applying skin prep or medi-honey and zinc oxide, and covering or leaving the wound open to air as directed. These orders specified the frequency of care, including every shift and as needed for soiling or dressing dislodgement. However, review of the Wound Care Treatment Administration Records (TAR) for April and May revealed multiple dates and shifts where there was no documented evidence that wound care was provided as ordered. The DON and Wound Care Nurse confirmed that the blanks in the TAR indicated the wound care was not completed on those dates and that the care was not provided according to the physician's orders. Facility policies required daily skin inspections during personal care, prompt identification and documentation of skin changes, and adherence to prescribed wound care treatments. The failure to provide wound care as ordered and to follow the facility's own policies for prevention and monitoring of pressure injuries resulted in a deficiency, as the resident did not receive the necessary care to prevent the development and progression of a pressure injury.