Failure to Provide Timely and Consistent Pressure Ulcer Care and Assessments
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure injuries for four residents. For one resident, weekly skin assessments were not completed after a certain date, and there was a delay in obtaining and implementing wound care orders after an unstageable pressure injury was identified. Additionally, dietary recommendations from the dietician were not implemented, and wound care treatments were missed on multiple days, with no documentation of resident refusal. Another resident was admitted with bilateral stage 4 pressure injuries to the heels, but wound care orders were not obtained or implemented until several days after admission, and head-to-toe skin assessments were not completed as required. Wound care was also missed on several days for this resident. A third resident experienced deterioration of an existing pressure wound, which progressed from stage 3 to stage 4 and increased in size. Wound care was not performed as ordered for ten days, and weekly skin assessments were not completed after a certain date. An intervention for a low air loss mattress, as specified in the care plan, was not implemented. For a fourth resident, wound care was not performed as ordered for ten days, and weekly skin assessments were not completed after a specific date. There was no documentation that this resident refused treatment for her wound. Observations and interviews revealed that staff were not consistently performing or documenting required skin assessments and wound care. The facility did not have a designated treatment nurse, and floor nurses were responsible for wound care and assessments, but these tasks were often not completed as scheduled. Staff interviews indicated a lack of accountability and follow-through, with missed documentation and communication lapses regarding wound care orders and changes in resident condition. Facility policies required notification of the attending physician for new skin alterations and evaluation and documentation of skin changes, but these procedures were not consistently followed.
Removal Plan
- Dietary recommendations for Resident #11 were approved with orders written.
- Consulting wound care physician was contacted by the Corporate Director of Clinical Operations regarding Resident #11's wound and treatment orders.
- Resident representative for Resident #11 was contacted to determine preferred wound care physician.
- Resident #11 scheduled to be seen by the wound care physician.
- Wound care consulting physician was contacted by the Corporate Director of Clinical Operations regarding Resident #12 to inform of most recent measurements and wound condition.
- Resident representative for Resident #12 was notified of current wound condition by the MDS Coordinator.
- Admitting nurse for Resident #12 was provided with individual education regarding ensuring residents admitted with a wound have orders for treatment, notifying the physician, and immediately rendering treatment upon admission.
- Wound care consulting physician was notified by the MDS coordinator regarding Resident #13's wound condition.
- Resident representative for Resident #13 was notified by the MDS Coordinator.
- All nursing staff present at the time of notation were provided with an in-service on how to document when a resident is not available for a visit by a consulting provider.
- Facility MDS coordinator evaluated all current wounds, measured wounds, and documented the condition of all wounds in the Skin Issue evaluation of the electronic health record.
- Nursing administration team compared all measurements and wound condition observations to previous measurement/condition to ensure any area of deterioration/worsening are immediately reported to the Wound Care Physician and the resident's attending physician.
- All nurses present at the time of notification were re-educated in the form of an in-service regarding completion of weekly skin assessments, including how to complete the assessment, what to look for, when to complete the assessment, what to document, and when to report skin issues.
- Nurses will be provided with notification of consequences for failure to complete scheduled skin assessments during their shift.
- Completion of skin assessments will be monitored by the Director of Nursing and by the designated Weekend Nursing Supervisor.
- A complete head to toe skin inspection was completed by the Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Assistant Corporate Director of Clinical Operations on all residents.
- Nurses present at the time of notification were in-serviced by the administrative nursing team regarding admitting a resident with wounds, informing the physician, obtaining orders for treatment, ensuring orders for treatment are initiated immediately, and inquiring about existing wounds when receiving report from the discharging facility.
- Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Facility Administrator were re-educated on reviewing the missing documentation report for the Treatment Administration Record from the electronic health record.
- The missing documentation report for Treatment Administration Records will be reviewed by the Director of Nursing during the morning clinical meeting.
- Facility Administrator will ensure review of missed documentation report, admission record review, admission order reconciliation, and review of the 24/72-hour report.
- Facility has begun the process of replacing the current consulting wound care physician with a wound care company that will be onsite weekly, physically examine and evaluate all residents with wounds, provide wound progress reports, training to staff, and work directly with facility management.
- Another provider has been contacted and is willing to provide wound care consultant nurse practitioner service.
- Facility Administrator and Administrative Nursing Team will review the nursing schedule to ensure one designated nurse is scheduled to review wounds, complete measurements, evaluate wound condition and prepare the weekly skin report at least once per week.
- Weekly skin report will be reviewed by the Administrative Nursing Team and the Facility Administrator to ensure all interventions are present including supplements/vitamins as recommended by the registered dietician, support surfaces are appropriate, and treatments are evaluated for effectiveness.
- Weekly skin report review meeting will occur on Tuesday of each week.
- The Assistant Director of Nursing will divide daily treatments/wound care between the day shift and night shift to allow floor nurses more time to complete the treatment/skin assessment processes.
- A daily stand-down meeting will be held by the Facility Administrator and Director of Nursing to ensure all assigned wound care tasks, documentation, recommendations, physician notifications, and physician orders are carried out appropriately.