Failure to Recognize, Assess, and Document Pressure Ulcer Deterioration and Provide Ordered Wound Care
Penalty
Summary
The facility failed to recognize, assess, and appropriately document the worsening symptoms of pressure wounds and to provide wound treatments as ordered for two residents. For one resident with multiple comorbidities, including diabetes, peripheral vascular disease, and severe cognitive impairment, the facility did not perform or document required wound care treatments on at least one occasion. Staff failed to notify the physician of significant changes, such as decreased intake, decreased urine output, and signs of wound infection, including malodorous and purulent drainage from a sacral ulcer. The resident's condition deteriorated over several days, culminating in a hospital transfer where the wound was found to be infected with both gram-positive cocci and gram-negative bacilli, and the resident was diagnosed with sepsis, dehydration, and failure to thrive. Interviews and record reviews revealed that staff did not consistently perform or document wound care as ordered, and there was a lack of communication regarding the resident's decline. Nursing staff, including RNs, LPNs, and CNAs, reported not recalling or not being aware of the need to notify the physician or document wound care treatments. The wound care nurse practitioner noted that the sacral wound had a strong necrotic odor and heavy purulent drainage upon assessment, and that the facility had not notified the physician about the resident's decline or signs of infection prior to the hospital transfer. Additionally, the treatment administration record showed missed documentation of wound care, and staff interviews confirmed that if documentation was missing, the treatment likely was not performed. A second resident with a deep tissue injury to the left heel also did not have wound care treatments documented as completed for multiple consecutive days, including weekends. The responsible nurse stated that treatments were generally performed but not always documented, and was unsure if treatments were completed on weekends. The facility's pressure ulcer policy required regular assessment, documentation, and physician notification for wound deterioration, but these procedures were not consistently followed for either resident.