Failure to Prevent Worsening of Pressure Ulcers and Delayed Wound Care Referrals
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent the worsening of pressure ulcers for two residents with existing pressure ulcers. For one resident admitted with pressure ulcers to the left ankle and sacrum, the care plan included interventions such as encouraging and assisting with turning, and physician orders required repositioning every two hours and the use of protective boots while in bed. However, the medical record did not show evidence that staff consistently repositioned the resident or applied the protective boots as ordered. An administrative staff member confirmed the lack of documentation for these interventions. For another resident admitted with a diagnosis of spinal cord compression, the initial physician's orders did not identify or address pressure ulcers. Four days after admission, deep tissue injuries to both buttocks were identified, and wound care orders were obtained the following day. The care plan was not updated to include a repositioning schedule until approximately one month after the injuries were first noted, despite wound assessments recommending repositioning every 2-3 hours. The medical record lacked evidence that staff implemented the recommended repositioning schedule. Additionally, the facility failed to process and coordinate timely referrals for wound care. There were delays in following up on wound clinic referrals, and the provider did not evaluate the resident's wound during a bedside visit. The resident's wounds deteriorated, progressing to a stage 4 pressure injury with acute cellulitis, and required hospitalization. The facility also did not provide a policy for processing referrals to outside agencies, contributing to the delay in wound care follow-up.