Failure to Provide Consistent Pressure Ulcer Prevention and Wound Care
Penalty
Summary
A deficiency occurred when a male resident with spastic quadriplegic cerebral palsy and other medical conditions developed a wound on his right calf due to friction from his wheelchair. Despite being identified as at risk for pressure ulcers, the resident did not have any wound care or therapy consult orders in place for nearly two months. Progress notes indicated that the wound was first documented as an abrasion with redness and was treated with normal saline, TAO, and a dry dressing, but there was no further documentation or follow-up on the wound for almost a month. Weekly skin assessments, as required by facility policy, were not completed for the resident. The last documented skin assessment before the deficiency was on 4/10, with the next not occurring until 5/29, despite the presence of a wound. During this period, there was no evidence of ongoing wound care, therapy consultation, or reassessment, and the wound deteriorated, developing granulation tissue and slough. The resident reported ongoing pain and that the wound had worsened due to continued friction from the wheelchair, with only a towel provided as a temporary measure. Interviews with staff revealed lapses in the facility's wound care processes, including a gap in wound care nurse coverage and issues with the electronic medical record system not generating skin assessment reminders. The charge nurses were responsible for weekly skin assessments during the interim, but these were not completed as required. The facility's own policy mandates weekly full-body skin assessments and thorough documentation, which was not followed in this case, resulting in inadequate care and monitoring of the resident's wound.