Failure to Ensure Timely Pressure Ulcer Care, Communication, and Equipment Settings
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. In one case, a resident with multiple comorbidities, including cellulitis, lymphedema, and chronic kidney disease, developed a sacral pressure sore that was not reported by nurse aides to a nurse until it was already unstageable. The wound was first identified by the Wound Care Nurse, who did not immediately notify the Wound Physician or enter treatment orders into the electronic record. As a result, there was a delay in initiating appropriate wound care, and the primary care nurses were unaware of the wound or any treatment orders during weekends. The Wound Physician was not consulted at the time of initial discovery, and the treatment plan was not implemented until several days later. Additionally, when the wound failed to heal, further diagnostic studies ordered by the Wound Physician, such as lab work and x-rays, were not completed in a timely manner due to a lack of communication and oversight, resulting in a prolonged period before the underlying infection and other complications were identified. In another instance, a second resident returned from hospitalization and was found to have an open area on the sacrum, but the initial assessment lacked detailed documentation. The Wound Care Nurse did not observe the sacral wound during her assessment, and there was a delay in obtaining and documenting treatment orders. A one-time dressing order was obtained, but no ongoing treatment plan was established or documented for several days. Communication lapses between nursing staff, the Wound Care Nurse, and the Wound Physician led to the wound not being properly addressed until it was identified as a Stage 4 pressure sore by the Wound Physician. Additionally, a change in the treatment plan for a heel wound was not transcribed into the electronic record, resulting in continued use of an outdated treatment. The facility also failed to ensure that the settings of a pressure-relieving air mattress were correctly adjusted for a resident's weight. The air mattress was observed to be set for a much higher weight than the resident's actual weight on multiple occasions, which could have compromised pressure relief. Staff interviews revealed a lack of clarity regarding responsibility for checking and maintaining correct mattress settings, and the Wound Care Nurse acknowledged that the setting was incorrect and should have been adjusted to match the resident's weight.