Failure to Provide Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received treatment and services consistent with professional standards of practice, as evidenced by multiple deficiencies in assessment, documentation, notification, and care planning for two residents with pressure ulcers. For one resident with multiple comorbidities, including end-stage renal disease, diabetes, and morbid obesity, the care plan lacked specific interventions for pressure ulcer prevention and treatment, such as repositioning and heel elevation. There were repeated failures to document wound assessments, measurements, and characteristics, as well as to notify the physician and family of new or worsening wounds. Treatment Administration Records (TARs) were missing documentation of completed treatments for identified wounds, and there was no evidence that all physician orders were obtained or followed for wound care. The resident experienced a decline in wound status, with wounds becoming infected and ultimately leading to hospitalization for septic shock, where extensive necrotic wounds and skin failure were documented. For another resident with a pressure area on the left outer ankle, the facility did not document when or why a Mepilex dressing was applied, and the dressing was initiated without a physician order. The clinical record lacked documentation of wound characteristics and failed to show that recommendations from an outside wound nurse were implemented or communicated to the physician or dietician. When the resident refused to wear an offloading boot, there was no documentation of alternative interventions to prevent further skin breakdown. Staff interviews confirmed that treatments were sometimes initiated without proper orders and that follow-up on physician communication, such as faxes, was inconsistent. Facility policy required systematic skin inspections, timely notification of physicians and families, individualized care planning, and thorough documentation of wound assessments and treatments. However, these procedures were not consistently followed, as evidenced by missing or incomplete documentation, lack of timely notifications, and failure to update care plans with appropriate interventions. Staff and administration acknowledged these deficiencies during interviews, noting issues with documentation, communication, and oversight of wound care.