Failure to Provide Timely and Accurate Pressure Ulcer Care Resulting in Harm
Penalty
Summary
The facility failed to develop and implement an accurate, comprehensive, and individualized pressure ulcer program for two residents who were at risk for and had existing pressure ulcers. For one resident, who had multiple comorbidities including weakness, cerebral infarction, atrial fibrillation, type 2 diabetes, and chronic kidney disease, the facility did not obtain timely treatment orders for known pressure ulcers upon admission. There were also errors in entering treatment orders, resulting in incorrect wound care being provided. The resident's pressure ulcers worsened, and prevention interventions such as repositioning and offloading were not implemented as required. This led to the resident being hospitalized for infection and sepsis related to pressure ulcers, and ultimately being placed on hospice due to complications from multiple antibiotic use for worsening wounds. Another resident, also requiring maximum assistance with bed mobility and transfers and at risk for pressure ulcer development, experienced a worsening of a right buttock pressure ulcer from stage 3 to stage 4. This occurred because medicated treatments, specifically Leptospermum Honey and Alginate Calcium, were not ordered or administered for several days. The wound increased in size and severity, with significant necrotic and slough tissue developing. The lack of timely and appropriate wound care interventions directly contributed to the deterioration of the resident's condition. Throughout the review period, there were repeated failures to ensure that wound care physician recommendations were accurately transcribed into physician orders and that the correct treatments were administered as prescribed. Documentation was inconsistent or missing, and there were lapses in implementing general pressure ulcer prevention measures such as regular repositioning, use of specialized mattresses, and prompt reporting of skin changes. These deficiencies resulted in serious, life-threatening harm to both residents, including hospitalization for infection, sepsis, and progression of pressure ulcers.
Removal Plan
- Resident #300 was assessed by Wound Care Physician #70 with orders received and followed by a licensed nurse, Assistant Director of Nursing (ADON)/Wound Nurse# 33.
- Resident #800 was assessed by Wound Physician #70 with new orders received and followed by a licensed nurse ADON/Wound Nurse# 33.
- An in-service was completed for ADON/Wound Nurse #33 by DON #40 and Regional Nurse #68 on the policy of Pressure Injuries: assessment, prevention, and treatment and the policy of physician notification.
- An in-service was completed for Minimum Data Set (MDS) Nurse #42, Registered Nurse (RN) #34, RN #27, RN #56, Licensed Practical Nurse (LPN) #44, LPN #25, LPN #65, LPN #30, and 26 Certified Nursing Assistants (CNA) by DON #40 on the policy of pressure Injuries: assessment, prevention, and treatment policy; completing head to toe assessment and documenting on skin sheet, if resident has skin alterations; documenting the initial wound observation; and contacting House Physician #66 to obtain treatment orders if not provided from the hospital.
- Any staff who had not received education will not work until education is completed. All staff had received the education.
- An in-service was completed for MDS Nurse #42, RN #34, RN #27, RN #56, LPN #44, LPN #25, LPN #65, LPN #30 by the DON #40 on notifying physician of any resident change in condition.
- Any staff who have not received education will not work until education is completed. All staff have received the education.
- A whole facility skin sweep was completed for 48 residents to identify any skin alterations by LPN #30 and ADON/Wound Nurse #33.
- Any residents with new skin alterations were reviewed by the DON #40 and House Physician #66 notified.
- No new pressure injuries were identified during whole house skin sweep.
- Treatment orders for 48 residents were reviewed by the Regional Nurse #68 to ensure that treatment orders are appropriate for any skin alterations.
- A list of any residents being followed by the wound care physician will be maintained by DON #40.
- For newly admitted residents, based on the admission skin assessment, the resident will be added to the wound consult as applicable.
- For current residents, any new skin alteration identified will be reviewed and added to the wound consult as applicable.
- An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with House Physician/Medical Director #66 and facility leadership DON #40, Administrator #41, MDS/RN #42, ADON/Wound Nurse #33, Regional Administrator #69, and Regional Nurse #68 on pressure ulcer care and plan of correction.
- An audit to ensure pressure ulcer care is being completed per policy will be conducted for five residents three times a week for four weeks and as needed (PRN) by the DON or designee. Any concerns will be forwarded to the QAPI committee for immediate follow up.
- An audit to ensure wound consults are accurate on the consult sheet and orders from wound consults are entered appropriately and assigned to the correct physician will be completed once a week for four weeks and PRN by the DON or designee. Any concerns will be forwarded to the QAPI committee for immediate follow-up.
- An audit to ensure residents being followed by the wound care physician is being maintained by the DON, newly admitted residents are added to the wound consult list as applicable, and current residents with any new skin alterations are added to the wound consult list as applicable will be conducted once per week for four weeks and PRN by the regional nurse consultant or designee. Any concerns will be forwarded to the QAPI committee for immediate follow-up.
- QAPI plan completed.