Failure to Provide Timely Pressure Ulcer Care and Diabetes Management
Penalty
Summary
The facility failed to provide safe and effective skin and wound care in accordance with facility policy and professional standards for a resident admitted with an unstageable pressure ulcer. Upon admission, the resident had a history of type 2 diabetes with diabetic neuropathy, an unstageable pressure ulcer to the right heel, and repeated falls. Despite these conditions, the baseline care plan did not address pressure ulcer treatment, prevention, or diabetes management. The Minimum Data Set (MDS) assessment triggered the need for care planning related to pressure ulcers, but a comprehensive care plan and physician orders for pressure ulcer management were not implemented until several weeks after admission. There was also no documentation of the resident's heel pressure ulcer or related skin assessments until a wound evaluation was completed weeks later, which noted a right heel blister present on admission and signs of infection. During the period from admission until the care plan was established, there was no evidence that a physician supervised the care of the resident's pressure ulcer, despite multiple provider visits. A nurse practitioner confirmed that a care plan for pressure ulcers should have been in place upon admission. The resident was eventually sent to the emergency department due to right leg edema, where they were found to have a stage 2 right foot ulcer, cellulitis requiring antibiotics, and acute hyperglycemia. The emergency department physician noted that the resident was not receiving prescribed insulin, and blood glucose was elevated. The nurse practitioner at the facility was unaware that insulin was not currently prescribed.