Failure to Provide Pressure Ulcer Treatment and Assessment
Penalty
Summary
A resident with multiple complex medical conditions, including quadriplegia, kidney disease, cirrhosis, and a history of bilateral below-knee amputations, developed a Stage IV pressure ulcer on the left ankle. Despite being at high risk for pressure ulcers and having a care plan in place that required regular wound assessments and treatments, there were no wound care treatment orders for the left ankle documented in the facility's records for the entire month of September. Additionally, there were no weekly skin or pressure ulcer assessments recorded during this period until after the resident was admitted to the hospital. Multiple wound care physician assessments documented the presence and progression of the Stage IV ulcer, with specific treatment plans outlined in the physician's notes. However, these orders were not transcribed into the facility's electronic medical record (EMR) or treatment administration records, resulting in the nursing staff being unaware of the required wound care interventions. Interviews with nursing staff revealed a lack of awareness regarding the resident's wound care needs, with several nurses and CNAs stating they did not know about the wound or did not perform any wound care. The wound care nurse, who was responsible for entering physician orders into the EMR, acknowledged missing the transcription of these orders, and as a result, wound care was not provided as required. The resident's condition deteriorated, with observations of soiled dressings, malodor, and exposed bone, ultimately leading to infection, sepsis, and the need for a left below-knee amputation. The facility's own policies required prompt notification of the physician and initiation of treatment orders in the absence of existing orders, as well as weekly skin and ulcer assessments, none of which were followed. The deficiency was identified through record review, staff and resident interviews, and direct observation, confirming that the facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection.