Failure to Provide Consistent Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents reviewed for wound treatment and services. Specifically, one resident with paraplegia and multiple complex wounds did not receive wound care interventions as ordered, including scheduled bandage changes, regular turning and repositioning, and being placed in a chair twice daily. Documentation and interviews revealed that wound care was not consistently provided, with missed dressing changes and inadequate implementation of physician and wound care specialist orders. As a result, the resident's wounds deteriorated, leading to hospitalization for severe sepsis and surgical wound debridement. Record reviews and staff interviews confirmed that wound care was not provided daily as ordered for two additional residents, with at least one instance where wound dressings were not changed for an entire day. Observations showed soiled and saturated dressings, and staff acknowledged that either the wound care nurse or charge nurses were responsible for providing wound care in the absence of the designated wound care nurse. However, this responsibility was not consistently fulfilled, and dressings were left unchanged, increasing the risk of infection and delayed healing. Interviews with residents, family members, and staff highlighted ongoing concerns about inadequate care, poor communication, and lack of responsiveness to resident needs. One resident and her family reported repeated complaints to facility leadership about missed turning, infrequent dressing changes, and being left in soiled conditions, with little to no resolution. Staff shortages, lack of continuity in wound care nursing, and inconsistent adherence to care plans and physician orders contributed to the deficiencies observed. These failures placed residents at risk of physical harm, including infection and wound deterioration.