Failure to Timely Update Pressure Ulcer Treatment After Worsening
Penalty
Summary
A resident with diagnoses including anemia, diabetes mellitus, and end stage renal disease was admitted to the facility with two stage 2 pressure ulcers and was dependent on staff for bed mobility and transfers. The care plan indicated that the resident had a pressure wound to the left ischium, which had previously healed but reopened as a stage 2 ulcer after a hospital stay. The care plan required staff to measure and record the wound's description and notify the physician of any changes or worsening. On assessment, the wound was found to have slough, which is only present in stage 3 or higher ulcers, but there was no documentation that the wound treatment or interventions were changed when the ulcer worsened. Further review showed that the wound continued to have slough and did not improve, yet no new treatment orders or interventions were implemented until over a month later. There was also a lack of physician documentation regarding the worsening wound status. During an interview, the DON confirmed that no documentation could be provided to show that interventions were changed when the wound worsened to a stage 3, and acknowledged that a new treatment order was not put in place until a month after the wound had worsened. Facility policy required physician evaluation and documentation of wound progress, especially for wounds not healing as anticipated, but this was not followed in this case.