Failure to Provide Comprehensive Pressure Ulcer Care Resulting in Harm
Penalty
Summary
The facility failed to develop and implement a comprehensive and effective pressure ulcer program, resulting in a lack of appropriate wound care for a resident with a chronic right heel wound. After returning from a hospitalization, the resident's wound care orders were not transcribed into the facility's electronic health record, and no wound care orders or documented dressing changes were in place for nearly a month. During this period, the resident's wound was not assessed or treated as required, and there was no evidence of interventions such as offloading or the use of heel boots, despite the resident's high risk for pressure ulcers and a history of complex wounds. The resident's wound deteriorated significantly, as noted by the wound nurse practitioner, with increased exudate and eventual infection. The resident required hospitalization for debridement due to gas gangrene and osteomyelitis of the right heel, resulting in significant exposure of the heel bone and a prolonged hospital stay with intravenous antibiotics. Upon return to the facility, there continued to be lapses in wound care, including the absence of proper dressing changes and failure to implement recommended interventions such as Prafo heel boots and a low air loss mattress. Documentation and communication failures persisted, with staff unable to locate wound care orders and no evidence of consistent wound care being provided. The situation escalated when staff discovered maggots in the resident's right heel wound, indicating severe neglect of wound management and hygiene. Multiple staff interviews confirmed that wound care was not performed as ordered, dressings were not changed as scheduled, and the resident was dependent on staff for all care needs. The facility's own wound care policy required verification of physician orders and documentation of wound care procedures, but these were not followed. The resident experienced actual harm, including repeated hospitalizations, wound deterioration, and infection, as a direct result of the facility's failure to provide appropriate pressure ulcer care and prevent further decline.