Failure to Implement Timely Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
Facility staff failed to implement timely and appropriate interventions to prevent and treat pressure injuries for three residents. For one resident, staff did not follow the wound nurse practitioner's recommendations for wound care, including delayed implementation of prescribed treatments and failure to provide an air mattress as recommended. Observations revealed improper infection control practices during wound care, such as not using personal protective equipment (PPE), cross-contaminating clean and dirty supplies, and placing clean gloves and wound cleanser on soiled bed linens. The resident reported not receiving heel boots as recommended, and documentation showed delays in updating care plans and treatment administration records to reflect new or worsening wounds. Another resident was admitted with moisture-related skin irritation and later developed a Stage 3 pressure ulcer. The wound nurse practitioner's recommendations for wound care and preventive measures, such as floating the heels, were not implemented. The treatment administration record did not show evidence of the recommended interventions being carried out, and the care plan was not updated to reflect the presence of the Stage 3 pressure ulcer or the necessary interventions. Interviews with staff revealed a lack of clarity regarding roles and responsibilities for implementing wound care recommendations, with some staff unaware of the process for ensuring that recommendations were entered into orders and care plans. A third resident developed a new wound during their stay, and the wound nurse practitioner's treatment recommendations were not implemented prior to discharge. The care plan was not updated to include the new wound, and the treatment administration record did not reflect the prescribed care. Staff interviews indicated that recommendations from the wound nurse practitioner were not always translated into actionable orders or care plan updates, and there was confusion about who was responsible for ensuring implementation. Facility policy required notification of providers and implementation of treatments as ordered, but this was not consistently followed.