Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a facility failed to ensure that a resident with pressure ulcers was assessed and provided necessary treatment and services consistent with professional standards of practice. The facility's wound care policy required documentation of wound care procedures, including the type of care given, assessment data, and the resident's response. However, review of the Treatment Administration Record (TAR) for a resident with Stage 3 and Stage 4 pressure ulcers revealed multiple dates where wound treatments were not documented as completed, and there was no documentation of refusals or reasons for missed treatments. The resident in question had significant medical conditions, including metabolic acidosis, pulmonary embolism, and hypertension, and was documented as having both Stage 3 and Stage 4 pressure ulcers. Physician orders were in place for specific wound care treatments, and the care plan directed staff to administer treatments as ordered and monitor for effectiveness. Despite these orders, the clinical record showed gaps in the documentation of wound care, with several days lacking evidence that treatments were performed or that the resident refused care. Interviews with facility leadership confirmed that dressing changes were not documented as completed and that there was a lack of effective communication regarding coverage for wound care when the wound nurse was unavailable. The Director of Nursing acknowledged that the wound nurse may have been assigned to other duties, and coverage for daily wound care was not effectively communicated to other staff, resulting in missed or undocumented treatments for the resident's pressure ulcers.
Plan Of Correction
R1 has discharged from this facility. A 7-day look-back audit will be completed on wound dressing documentation to ascertain no other residents were affected. The DON will educate the Wound Nurse and Nursing Staff on the facility wound care policy. The DON/Designee will audit wound dressing documentation weekly for 2 weeks to ensure documentation is completed. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed.