Failure to Provide Consistent and Adequate Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to provide consistent and adequate wound care for a resident with multiple complex medical conditions, including acute osteomyelitis, cutaneous abscess, diabetes with chronic kidney disease, and end-stage renal disease. Upon admission, the resident had documented wounds, specifically bilateral heel ulcers with osteomyelitis, and was discharged from the hospital with orders for ongoing wound care and evaluation by a wound care team. However, review of the resident's records revealed a lack of timely wound care orders and documentation, with no wound care orders entered until more than two weeks after admission, despite the presence of wounds requiring attention. Nursing notes and treatment administration records showed inconsistent documentation of wound assessments and care. Several entries noted the presence of wounds but indicated that no special care was provided, and there was no evidence of wound care being performed or documented on multiple days. Interviews with staff confirmed that wound care was not provided in the absence of provider orders or documentation in the treatment administration record. The skin treatment nurse acknowledged assessing the wounds but did not ensure that appropriate orders were entered or that care was documented. The resident and his family also reported that dressing changes were not performed as needed, and requests for wound care were often delayed or unaddressed by nursing staff. The deficiency culminated when the resident was evaluated by a podiatrist, who found the left heel wound to be neglected and in need of urgent care, resulting in a recommendation for immediate hospital transfer. The hospital record later confirmed that the resident's left foot and leg were amputated below the knee. The lack of consistent wound care, failure to follow up on hospital discharge orders, and inadequate documentation and communication among staff directly contributed to the resident not receiving care that would promote wound healing.
Removal Plan
- Initiate a new admit audit to ensure all tasks and admissions items are complete and confirm any outstanding items as complete during the stand down process.
- Perform QAPI as an education piece and update to wound care order verification process.
- Educate the team on the new clinical review protocol, including reviewer of all new admit orders, LPN unit manager, unit manager, director of nursing, treatment nurse, SHTL, admissions director, and Administrator.
- Admission is to notify the IDT team that a resident is admitting with wounds.
- Unit manager and/or designee will review the orders with the provider.
- If the wound is thought to be complex or needs additional oversight, the NExcell provider will be contacted.
- Hold weekly wound care meeting by the IDT team to ensure process is followed and all orders are entered timely, appropriately, updated care plan, accurate care plan, pictures taken with the swift phone.
- Conduct whole house skin sweep audit to identify any undocumented wounds.
- Confirm all treatment orders are in place and accurate.
- Audit all care plans to ensure accuracy per wound orders.
- Re-educate direct care staff on Wound Documentation and inputting orders upon admission.
- Re-educate Center Nurses on completion of skin assessments weekly per schedule.
- Educate nurses on their responsibility with communication with management and provider for the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds).
- Educate nurses on Genesis wound processes which include the DIMES, timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds.
- Educate CNA's on the change in condition process for CNA's (including skin changes) and stop and watch.
- Ensure 100% of available staff have been educated on these processes. Any staff member that has not been scheduled, on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift.
- Director of Nursing/Designee will audit education sign-off sheets to ensure that all nursing staff receive the education mentioned above.
- Director of Nursing/Designee will conduct 5 random audits of Residents that have wounds for skin assessment, order accuracy and for wound care process abidance. This will be audited weekly for 12 weeks.
- DON/designee and the Administrator/designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with the plan. The audits will be brought to the QAPI committee for 3 months.
- Administrator will oversee the QAPI committee.