Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. For one resident with chronic wounds and multiple comorbidities, the Wound Physician's orders for pressure sore treatment were unclear regarding the frequency of dressing changes, and staff did not seek clarification. Documentation showed inconsistencies and contradictions in the treatment administration records, with some staff signing off on dressing changes they did not perform and others unaware of their responsibilities. The resident experienced significant wound drainage, odor, and pain, and despite requests for a dressing change, the request was denied. Subsequently, maggots were found in the resident's pressure sore, which was attributed by a diagnostic entomologist to wound drainage attracting flies. The event was distressing for the resident and was witnessed by multiple staff members. Another resident was admitted with a hospital-acquired sacral pressure sore, but the facility failed to obtain and initiate treatment orders upon admission. Nursing staff were unclear about their responsibilities for wound care, with some nurses unaware they were assigned to the resident or unable to access the necessary information to perform dressing changes. Documentation of dressing changes was missing for several days, and interviews revealed that some staff did not perform or document wound care, assuming it was the responsibility of a treatment nurse who was not present. The responsible party for the resident reported that there were days when the resident's pressure sores were not changed. A third resident developed new unstageable pressure sores, and although a physician assistant verbally instructed staff to keep the resident off the affected area and to consult the wound nurse, the instructions were not recalled or documented by the assigned nurse. There was a lack of clarity and follow-through regarding wound care orders and interventions for this resident as well. Across these cases, the facility failed to ensure clear communication of wound care orders, timely and appropriate dressing changes, and staff awareness of their responsibilities for pressure ulcer care.