Failure to Provide Timely and Comprehensive Pressure Ulcer Care
Penalty
Summary
A resident with a history of pressure injuries, severe cognitive impairment, and total dependence for care developed a pressure injury on the left ear. The initial discovery of the wound was not followed by a comprehensive assessment, as required by facility policy. Documentation was incomplete, with missing measurements, wound staging, and a lack of timely notification to the medical provider. The wound was first noted on 5/2, but there was no evidence of provider notification or treatment orders until 5/4. Additionally, there was confusion regarding who documented the initial finding, as the nurse listed was not present in the facility at the time. After the wound was identified, the care plan was updated to include the use of a neck pillow to offload pressure from the ear. However, multiple observations by the surveyor found the resident without the neck pillow, and staff interviews revealed a lack of awareness about this intervention. The resident was repeatedly observed with direct pressure on the affected ear, contrary to the care plan. Staff members, including CNAs and LPNs, denied knowledge of the neck pillow intervention, and there was no evidence that the intervention was consistently implemented. Despite recommendations from the wound nurse practitioner and facility wound nurse for daily wound treatments, staff continued to provide care only three times a week for several weeks. This was not in accordance with the recommended frequency, and the wound subsequently worsened, doubling in size. No additional interventions were implemented when the wound deteriorated. Comprehensive wound assessments were not consistently completed, and provider recommendations were not promptly followed. The facility failed to ensure that the resident received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries.