Failure to Provide Timely and Consistent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to promote healing and prevent new pressure ulcers for one resident with significant risk factors and existing wounds. The resident, an elderly female with severe cognitive impairment, bowel incontinence, immobility, and multiple comorbidities, was admitted with a stage 2 sacral pressure ulcer, deep tissue injury to the left heel, and a surgical abdominal wound. Despite being identified as high risk for pressure ulcers, the facility did not ensure timely wound care interventions, as there was a delay between the physician's referral to wound care and the first visit by the wound care specialist. Documentation showed that wound treatments were not consistently administered, and there were gaps in the administration of prescribed nutritional supplements and vitamins intended to support wound healing. The sacral wound deteriorated from a stage 2 to a stage 4 ulcer, eventually measuring 7 cm by 13 cm by 3 cm, and required debridement for necrotic tissue. The facility did not implement new interventions when the wound failed to heal, and there was no evidence of regular wound assessment or timely notification to the provider when the wound worsened. Additionally, the care plan lacked specific details about the location of wounds, and interventions such as turning and repositioning were not consistently documented or performed. Staff interviews revealed confusion and inconsistency in documentation practices, with some staff unable to verify if repositioning was done as required, and others reporting that documentation systems did not allow for accurate recording of care provided. Observations and interviews indicated that the resident was often found in the same position for extended periods, and there was a persistent odor in the room, suggesting inadequate hygiene and wound care. Family members reported not being informed about the wound's condition and had to intervene to secure emergency medical attention when the resident became lethargic and the wound appeared significantly worsened. The resident was subsequently hospitalized with fever and sepsis, and the hospital assessment found the sacral wound to be larger and more severe than previously documented by the facility. Similar failures in repositioning and documentation were observed for two other residents, indicating a pattern of deficient care.