Failure to Provide Timely Pressure Ulcer Care and Treatment Orders
Penalty
Summary
The facility failed to provide necessary and timely pressure ulcer care for two residents, resulting in delayed treatment and lack of appropriate wound management. One resident was admitted with a stage 2 pressure ulcer and additional wounds, but did not have wound care orders or treatments initiated until several days after admission. Documentation shows that from the time of admission, there were no wound care orders, no wound consult, and no wound care documented on the Medication Administration Record (MAR) until nearly a week later. Facility staff, including the ADON, DON, and Administrator, confirmed that wound care orders should be in place upon admission or within 24 hours, and acknowledged that the lack of orders and treatment placed the resident at risk for wound deterioration and infection. Another resident was admitted with multiple complex wounds, including two stage 4 pressure ulcers, several unstageable wounds, venous and arterial ulcers, and a diabetic foot ulcer. The initial skin assessment identified these wounds, but orders for wound care and a wound consult were not entered or implemented until several days after admission. Additionally, the resident was prescribed IV antibiotics for wound infection, but the medication was not administered until several days after admission. Interviews with nursing staff and practitioners revealed confusion and lack of clarity regarding responsibility for entering and implementing wound care orders, as well as a lack of communication and follow-up to ensure that all necessary treatments were started promptly. Observations and interviews further revealed that there was no consistent process for clinical review of new admissions to ensure accuracy and completeness of wound care orders and treatments. Staff members were unclear about their roles and responsibilities in the wound care process, and there was no timely follow-up to identify and correct errors or omissions in the admission process. As a result, both residents experienced significant delays in receiving appropriate wound care and treatment, as documented by the lack of orders, delayed administration of medications, and missed wound consults.