Failure to Notify Provider and Update Care Plan for Worsening Pressure Ulcer
Penalty
Summary
A resident was admitted to the facility with a left femur fracture and a stage 2 pressure injury to the sacrum. Upon admission, the care plan addressed the existing pressure ulcer. Over the course of the resident's stay, wound assessments documented a deterioration of the sacral pressure injury, progressing from stage 2 to an unstageable wound with suspected infection. Despite this change, there was no documentation that the resident's provider was notified of the wound's deterioration or suspected infection as of the assessment date when the change was noted. Additionally, the care plan was not updated to reflect the worsening condition of the pressure injury or to include new interventions after the wound became unstageable and appeared infected. Staff interviews confirmed that no provider notification occurred and no new interventions were added to the care plan following the wound's decline. The resident was later admitted to the hospital with an infected unstageable pressure injury to the sacrum.