Failure to Provide Timely and Accurate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate and timely pressure ulcer care for two residents, resulting in deficiencies in wound management and prevention. For one resident with a history of congestive heart failure, respiratory failure, diabetes, and stage four kidney disease, a physician's order was in place to treat a pressure ulcer on the left heel. However, during wound care, a registered nurse mistakenly treated the right heel, which no longer had a pressure ulcer, instead of the left heel as ordered. The nurse confirmed the error after it was pointed out, and the facility's policy required adherence to physician orders for wound treatment. Another resident, admitted after hip replacement surgery and with stage three kidney disease and hypertension, was identified as being at risk for skin breakdown. Initial skin assessments were inaccurately dated, and the resident developed pressure ulcers on the right upper buttock and coccyx, which later merged into a larger wound. Treatment for these ulcers was not initiated until several days after the wounds were first noted, despite physician orders being obtained. Additionally, deep tissue pressure injuries were identified on both heels, but treatment was delayed by a day after the injuries were discovered and orders were received. Interviews with nursing staff and the Director of Nursing confirmed that documentation was not completed on the correct dates and that treatments were not started promptly as required by facility policy. The facility's Skin Integrity Management Policy specified that treatment plans should be established and implemented for residents with pressure ulcers, but these procedures were not consistently followed for the affected residents.