Failure to Ensure Wound Care Nurse Competency Resulting in Pressure Ulcer Development and Deterioration
Penalty
Summary
The facility failed to ensure that nursing staff, specifically a newly hired wound care nurse, possessed the appropriate competencies and skill sets necessary for the care of residents with wounds. Clinical record reviews showed that the facility did not provide treatment and services consistent with professional standards of practice to prevent the development of pressure ulcers, resulting in new pressure ulcers for several residents. Additionally, the facility did not provide adequate treatment and services to promote healing and prevent infection, leading to the worsening or deterioration of existing pressure ulcers in multiple residents. During an interview, the DON confirmed that the wound care nurse was responsible for wound rounds and implementing physician recommendations but was unaware of the need to change orders. The facility was unable to provide documentation of wound care competency for the nurse prior to the survey.