Failure to Provide Timely Wound Care and Follow-Up
Penalty
Summary
A resident with a history of stroke, right-sided hemiplegia, and severe cognitive impairment developed pressure ulcers on both buttocks. The care plan identified the resident as high risk for skin integrity issues and included multiple interventions such as medication administration, wound care per physician orders, use of barrier creams, and regular skin assessments. Despite these interventions, documentation showed that the resident's wounds deteriorated over time, with increasing drainage, foul odor, and the development of eschar. The facility staff communicated with both the primary care provider (PCP) and the wound center physician regarding the resident's condition, but there was confusion and lack of clarity about wound clinic appointments and follow-up care. On several occasions, staff noted worsening wound conditions and communicated these findings via fax to the physicians. However, there was a failure to ensure timely follow-up and coordination between the facility, the PCP, and the wound center. For example, the facility believed the resident had a wound clinic appointment on a certain date, but no such appointment was scheduled, and there was no documentation of follow-up or notification to the wound center physician about the deteriorating wound. Weekly skin assessments continued to show worsening wounds, but the facility did not escalate care or ensure the resident was seen sooner by the wound specialist, even when staff hoped for more urgent intervention. Ultimately, the resident developed severe symptoms including respiratory distress, fever, and a large buttock ulcer, leading to hospital admission. Hospital records indicated the resident was septic with acute respiratory failure, and the wound was identified as a likely source of infection. Staff interviews revealed gaps in wound care knowledge and assessment, as well as uncertainty about wound clinic appointments and communication with providers. The facility's failure to provide treatment and care in accordance with professional standards, including timely follow-up and coordination with wound care specialists, contributed to the resident's decline.