Failure to Timely Implement Pressure Ulcer Treatment and Nutritional Interventions
Penalty
Summary
The facility failed to implement timely and appropriate treatment and interventions to promote healing and prevent new pressure ulcers for a resident who was identified as having a pressure ulcer upon readmission from the hospital. Upon return, the resident was noted to have an open wound to the coccyx, but there was no clear documentation of the unit of measurement, and no wound treatment order was in place until five days after the wound was identified. During this period, the resident did not receive wound care as per facility policy, and the recommended nutritional supplement for wound healing, Prosource, was not ordered or administered despite a registered dietician's recommendation. Subsequent wound assessments documented a decline in the resident's skin condition, with the development of additional wounds and progression of an existing wound from stage 2 to stage 3. The treatment administration records and medication administration records showed inconsistencies and delays in implementing wound care orders and nutritional interventions. There was also a lack of documentation for wound assessments on certain dates, and new treatment orders were not consistently reflected in the resident's records. Direct observation and interviews confirmed the presence of multiple pressure ulcers at different stages and locations, and staff acknowledged the delay in initiating wound care and the failure to implement the recommended nutritional support. The resident's wounds increased in number and severity during this period, indicating a lack of adherence to the facility's skin integrity and pressure ulcer prevention policy and failure to follow professional standards for wound management.