Failure to Provide Appropriate Pressure Ulcer Care and Timely Interventions
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a facility-acquired pressure ulcer. The resident, who had significant comorbidities including end-stage renal disease and diabetes, developed multiple wounds during their stay, including a left iliac crest pressure injury and sacral wounds. There were significant delays and inconsistencies in wound assessment and treatment orders, with documented discrepancies between wound care provider recommendations and the actual orders transcribed and implemented by nursing staff. For example, wound care interventions recommended by the wound care team were not consistently reflected in the Treatment Administration Record (TAR), and antibiotics were not always administered as prescribed, particularly in relation to the resident's dialysis schedule, resulting in subtherapeutic dosing. Documentation revealed that wound care interventions were not promptly added to the resident's care plan, with a delay of 21 days after wounds were first identified. There was also a lack of documentation regarding the resident's reported noncompliance with repositioning and wound care, as noted by the wound care provider, with no corresponding nursing or CNA notes, risk/benefit documentation, or care plan updates to address these issues. Additionally, there was a failure to initiate and document referrals for higher-level wound care as recommended by external providers, and the facility did not coordinate or document efforts to ensure the resident attended outpatient wound care or follow-up appointments, despite family requests and external provider recommendations. Throughout the resident's stay, wound healing was minimal, and infections persisted despite multiple rounds of antibiotics, which were at times administered incorrectly or not as ordered. The lack of timely and appropriate wound care interventions, poor communication and documentation among staff, and failure to coordinate necessary higher-level care contributed to the resident's hospitalization with sepsis and subsequent death. The facility's actions and inactions directly resulted in a deficiency related to the provision of pressure ulcer care and prevention of new ulcers.