Failure to Provide and Document Wound Care for Pressure Injury
Penalty
Summary
A resident with cognitive impairment and multiple chronic medical conditions, including sepsis and type 2 diabetes, was admitted to the facility with a documented sacral pressure injury and other skin conditions. The resident's care plan specified that the sacral wound should be evaluated and treated per physician's orders, with regular assessments, documentation, and monitoring. Despite these requirements, there was no documentation of wound care treatment, dressing changes, wound staging, wound assessments, or measurements for the sacral pressure injury from admission through discharge. Nursing staff submitted a wound care consultation at admission, and the Wound Care Nurse identified the sacral wound. However, the Wound Care NP did not assess or treat the sacral pressure injury during the resident's stay, and no wound care orders were provided or implemented for this wound. The facility's electronic medical record (EMR) contained no evidence of treatment or monitoring for the sacral wound, and staff interviews confirmed that if care was not documented in the EMR, it was not performed. There was also no evidence that nursing staff followed up with the provider regarding missing orders, notified the DON or Administrator, or escalated concerns about the lack of treatment. Interviews with the DON, Wound Care NP, Wound Care Nurse, and other staff revealed a lack of clarity and follow-through regarding responsibility for ensuring wound care was provided and documented. The Wound Care NP and Wound Care Nurse both acknowledged that the sacral wound was missed and left untreated, possibly due to a transition in the wound care documentation system. Staff could not explain why the absence of treatment orders was not escalated, and there was no documentation of staff training related to wound care order, prevention, and management during the relevant period.