Failure to Provide Timely Pressure Ulcer Care and Provider Notification
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with significant risk factors, including immobility, obesity, diabetes, and a history of pressure ulcers. The staff did not notify the provider when the resident developed peeling on both heels, nor did they document or act on this finding in a timely manner. There was a delay in obtaining physician orders to address the skin issues, and the location and stage of the developing pressure ulcer were repeatedly misidentified in the medical record. Over several weeks, the wound deteriorated, showing signs of infection, increased drainage, odor, and pain, but the provider was not notified of these changes or the wound's worsening condition. The facility also failed to ensure timely wound care appointments for the resident. After a wound care referral was ordered, there was a 12-working-day delay before any documented attempt to schedule an appointment. When appointments were missed or could not be scheduled due to transportation issues, the provider was not informed. Staff interviews confirmed that the provider was not notified of missed appointments or the resident's deteriorating wound, and there was no documentation of attempts to seek alternative transportation or escalate the issue. The resident's wound continued to worsen, eventually leading to severe infection, sepsis, and the need for a below-knee amputation after transfer to the hospital. Throughout the period of noncompliance, staff failed to follow facility policy and professional standards of practice regarding pressure ulcer prevention, assessment, and communication. The medical record lacked evidence of appropriate provider notification, accurate wound staging, and timely intervention. Interviews with nursing staff, the DON, and the medical director confirmed that required notifications and actions were not taken, and that the breakdown in communication and care coordination contributed to the resident's harm.