Failure to Provide Pressure Ulcer Care and Prevent New Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and promote the healing of pressure injuries for two residents, resulting in a deficiency. One resident was admitted with multiple diagnoses, including lymphedema, venous insufficiency, dementia, and chronic kidney disease, and had a documented stage 2 pressure injury on the right buttock upon admission. The hospital discharge summary included specific wound care instructions, but these were not incorporated into the resident's care at the facility. There was no evidence that the physician was notified of the hospital's wound care orders, and the facility did not develop or implement a comprehensive pressure injury care plan for this resident. Additionally, recommended treatments from the wound physician were not transcribed into the treatment administration record, and there was a lack of consistent and comprehensive wound assessments. Staff interviews revealed that the resident often refused care and was independent with some activities, which contributed to challenges in providing skin assessments and wound care. However, documentation and interviews indicated that staff did not consistently attempt or document thorough skin checks, particularly of the buttocks, and there was confusion among staff regarding wound locations and the staging of pressure injuries. The wound physician's recommendations were not communicated effectively, and there was a lack of follow-through in implementing treatment orders. The resident was eventually discharged to an assisted living facility, where staff identified multiple open wounds, some with signs of infection and no dressings or ointments present, leading to a hospital admission for further evaluation. A second resident developed three stage 2 pressure injuries within 15 days, and the care plan was not updated in a timely manner. The resident, who was at risk for pressure injuries, did not receive an air mattress for pressure relief for 14 days and subsequently developed an unstageable pressure injury. The facility's own policy required comprehensive assessment, timely care planning, and implementation of physician orders for wound care, but these protocols were not followed for the residents reviewed, resulting in the identified deficiencies.