Failure to Timely Identify and Treat Advanced Pressure Ulcer
Penalty
Summary
Facility staff failed to identify a pressure ulcer in a resident until it had progressed to an advanced stage, with more than 70% slough present at the time of discovery. Upon identification, staff performed a one-time wound treatment without a physician order and did not obtain ongoing treatment orders or notify the physician. There was no documentation of further wound care or assessment for five days, until a wound specialist evaluated the resident and performed sharp debridement. The wound continued to deteriorate over the following month, eventually exposing bone and requiring additional interventions. Throughout the course of the resident's care, there were repeated delays and omissions in implementing wound care orders and recommended interventions. The facility failed to timely implement wound specialist recommendations, including changes in wound care regimen and obtaining an x-ray to rule out osteomyelitis, which was delayed for 18 days after being recommended. Documentation revealed missed wound treatments, lack of evidence for required repositioning every two hours, and incomplete or missing records of care provided. Staff interviews confirmed that gaps in the treatment administration record indicated missed care, and that there was no documentation to support that repositioning was consistently performed as ordered. The facility's QAPI (Quality Assurance Performance Improvement) process was found to be inadequate, with incomplete forms, lack of root cause analysis, and no evidence of completed audits or education related to the identified deficiency. The DON and other staff were unable to provide documentation of corrective actions, education, or audits that addressed the issues with wound care and documentation. Facility policies reviewed during the survey emphasized the importance of timely identification, assessment, and treatment of pressure injuries, but these standards were not met in the care of the resident.