Failure to Administer Prescribed Antibiotics and Provide Standard Wound Care for Stage 4 Pressure Ulcer
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards for a resident with a stage 4 sacral pressure ulcer. The resident, who had multiple comorbidities including cerebral infarction, hemiplegia, hypertension, peripheral vascular disease, and was dependent on staff for all activities of daily living, experienced a significant worsening of her pressure ulcer. The wound increased in size, exhibited signs of infection, and developed exposed bone, with documentation showing a progression from 2.20 cm x 1.10 cm x 0.10 cm to 5.40 cm x 6.00 cm x 2.30 cm over a short period. The wound was noted to have purulent, malodorous drainage and slough, and the resident showed signs of systemic infection, including elevated heart rate and withdrawal. Despite clear orders from the wound care nurse practitioner to start a new antibiotic regimen (Cefdinir), the medication was not administered as prescribed. There was confusion and miscommunication regarding the duration and documentation of the antibiotic order, with staff interviews revealing discrepancies between verbal and written orders. The resident did not refuse wound care or antibiotics according to multiple staff and family interviews, yet the antibiotic was not given, and wound care was inconsistently provided. The resident's care plan included interventions such as regular repositioning, wound treatments, and use of a low air loss mattress, but interviews and observations indicated that repositioning and offloading were not consistently performed. Family members were not adequately informed about the severity of the resident's condition, and staff repeatedly communicated that the resident was well, despite the worsening wound and infection. The resident was eventually transferred to a hospital, where she was found to have severe osteomyelitis and sepsis related to the untreated and deteriorating pressure ulcer. Hospital staff observed that the wound appeared not to have been treated for several days, and the resident was in severe pain. The failure to administer prescribed antibiotics and provide consistent wound care directly contributed to the resident's decline.