Failure to Provide Wound, PEG Tube, and Hygiene Care Resulting in Resident Harm
Penalty
Summary
The facility failed to protect a resident from neglect by not providing adequate care for multiple skin conditions, a percutaneous endoscopic gastrostomy (PEG) tube, and personal hygiene. After returning from a hospital stay, the resident had documented pressure ulcers and skin tears, with specific wound care orders written in the Treatment Administration Record (TAR). However, there was no documentation that these wound treatments were performed, as the TARs were not signed off for any of the days the orders were active. The resident's care plan noted a history of resistance to care, but there was no indication in the TAR that the resident refused any treatments during this period. The resident was also not provided with proper bathing activities, as there were no showers documented and only two bed baths recorded during the relevant timeframe. Upon transfer to the hospital, the resident was found to be generally soiled with dirt and feces in skin folds, and had yeast-like exudate. Hospital records also noted that the resident had heart monitor lead stickers from a previous hospitalization still attached, and a PEG tube dressing adhered to the skin by drainage, with no facility documentation of PEG tube site care or cleaning orders. The hospital identified an infected sacral pressure ulcer, which, along with pneumonia, led to a diagnosis of septic shock. Additionally, the hospital found dressings on the resident's skin that were dated from a previous hospitalization, indicating that dressing changes had not been performed as required. The Center Nurse Executive confirmed that there was no documentation of wound care or dressing changes in the facility's records, and the facility was unaware of the hospital's findings regarding the lack of dressing changes. These failures resulted in actual harm to the resident, including wound infection and hospitalization.