Failure to Prevent and Treat Pressure Ulcers and Complete Wound Care as Ordered
Penalty
Summary
Surveyors identified multiple deficiencies related to the prevention and treatment of pressure ulcers and wound care. In one case, a resident with dementia, chronic inflammatory demyelinating polyneuritis, and a stage 4 pressure ulcer did not consistently receive wound care as ordered. Documentation showed missed dressing changes, lack of supplies (specifically Anasept cleanser), and infrequent bathing, with gaps of up to ten days between baths. Progress notes indicated that wound treatments were not completed for various reasons, including the resident sleeping, dressing being intact, or supplies being unavailable. The resident's wound worsened, and the nurse practitioner noted a significant decline, ultimately leading to hospitalization for wound evaluation. The resident later died from osteomyelitis and sepsis, with the nurse practitioner attributing the outcome to missed dressing changes and inadequate hygiene. Another resident, also with dementia and generalized muscle weakness, was identified as being at risk for pressure ulcers due to immobility and incontinence. However, the care plan did not address this risk until after a pressure ulcer had developed. Weekly skin assessments were not completed as ordered, and there was a lack of documentation and follow-up when an open wound was first observed. The resident's air mattress was set incorrectly for their weight, and staff failed to reposition the resident as required, with observations showing the resident remained in the same position for extended periods. Additional deficiencies were found with other residents. One resident with multiple stage 2 and unstageable pressure ulcers had an air mattress set for a weight much higher than their actual weight, and staff were unsure of the correct settings. The resident was not repositioned every two hours as required, and staff did not respond to complaints of pain until prompted. Another resident did not receive wound care as ordered, with the DON using the wrong medication for a wound treatment due to not being aware of a recent order change. These findings demonstrate failures in implementing and following care plans, completing wound care as ordered, and ensuring proper preventive measures for pressure ulcer management.