Failure to Implement Wound Treatment Orders and Prevent Pressure Ulcer Development
Penalty
Summary
A resident with multiple complex medical conditions, including sepsis, pneumonia, epilepsy, neuromuscular dysfunction of the bladder, dysphagia, diabetes with neuropathy, and aphasia, was admitted to the facility and identified as being at high risk for developing pressure ulcers based on Braden Scale assessments. The resident was nonverbal, required total assistance for all activities of daily living, and was unable to reposition herself in bed. Initial skin assessments upon admission showed intact skin, but subsequent documentation was lacking until after a hospitalization. On one occasion, a registered nurse documented the presence of two blisters on the resident's buttocks and notified a telemedicine provider (eCare), who gave orders for wound care, including the application of Opti Foam dressings and continued repositioning. However, there was no evidence that these orders were entered into the electronic medical record, implemented, or communicated to the wound nurse, primary care provider, or the resident's representative. There was also no documentation of a skin assessment of the blisters, nor was there evidence of regular repositioning or monitoring as required by the resident's care plan and facility policy. The only documentation related to the blisters was a progress note and a scanned eCare note, neither of which were signed or acknowledged by nursing staff. Interviews with staff revealed confusion and lack of recall regarding the wound care orders and the resident's condition. The facility's skin integrity policy required systematic assessment, documentation, notification, and intervention for skin impairments, but these steps were not followed. As a result, the blisters went untreated for several days, and the resident developed a stage 2 pressure ulcer on her sacrum, which was identified during a subsequent hospital admission. There was no evidence that the required notifications, assessments, or interventions were completed in accordance with facility policy.