Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice for three residents. One resident was admitted with a hospital-acquired stage 2 pressure injury to the sacrum, but did not receive a comprehensive assessment or treatment for the injury until several days after admission. Documentation was unclear regarding the staging of the wound, and there was no evidence of monitoring or treatment orders in place until days later. Staff interviews revealed a lack of awareness about the presence of the pressure injury, and the care plan and CNA care card did not specify the wound or interventions related to it. Another resident was admitted with a pressure injury that was incorrectly staged as a stage 2 when it was actually a stage 3. No treatment was initiated for three days after admission, and the care plan included incomplete instructions for interventions such as the use of barrier cream. When the wound worsened and increased in size, the treatment plan was not revised, and the same intervention was continued despite the lack of improvement. Documentation of wound care was also inconsistent, with several shifts lacking evidence that treatments were completed as ordered. A third resident developed a blister on the thumb that progressed to a stage 3 pressure injury, apparently related to the use of a palm guard. There were no interventions in place prior to the development of the injury, and after the injury occurred, the interventions implemented were not clearly defined. The care plan was not updated to reflect the new wound, and there was no documentation of a therapy referral or comprehensive assessment of the wound. These deficiencies were identified through interviews, record reviews, and observations, and were not addressed in a timely or systematic manner as required by facility policy.