Failure to Implement Wound Care Orders and Maintain Pressure Relief Equipment
Penalty
Summary
The facility failed to follow and implement wound care orders from the Wound Nurse Practitioner (NP) in a timely manner for a resident with multiple complex wounds, including stage 3 pressure ulcers and chronic skin conditions. Orders for wound dressings, specialty equipment such as a low air loss mattress, and heel float boots were not promptly initiated or maintained as directed. Documentation shows that wound care treatments were delayed, incorrect treatments were applied, and there were multiple instances where dressing changes and skin assessments were either not performed or not documented as completed according to the NP's orders. The resident's low air loss mattress, which was ordered to provide pressure relief and prevent further skin breakdown, was not maintained in proper working order. Staff, family members, and the resident reported that the mattress frequently lost air, leaving the resident lying on a hard surface, which caused significant pain and discomfort. The mattress was described as being held together with duct tape, with hoses repeatedly disconnecting and the air pump malfunctioning. Despite repeated notifications to facility leadership and maintenance, the issues with the mattress persisted for an extended period before a replacement was provided. As a result of these failures, the resident experienced worsening of wounds, which became infected with multiple organisms including MRSA, Pseudomonas, Enterococcus faecalis, and ESBL E. coli. The infections led to several hospitalizations, surgical debridement, and the need for intravenous antibiotics. The facility's lack of timely and appropriate wound care, failure to maintain essential equipment, and inadequate documentation directly contributed to the deterioration of the resident's condition and the escalation of her wounds.
Removal Plan
- Facility wound care policy was reviewed by President of Operations and was found to be in compliance with state and federal regulations.
- Director of Nursing or designee initiated in-servicing for all nursing staff on the wound care policy and procedures.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on wound care policy and procedures.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant to ensure that all wound orders are carried out and all interventions are in place.
- Director of Nursing or designee will conduct audits of all wound care orders and interventions weekly.
- The Director of Nursing or designee will interview 3 staff members, 3 times weekly to ensure that staff understand wound care policies and procedures.
- Maintenance Director checked all Low Air Loss (LAL) mattresses to ensure proper functioning.
- Maintenance will perform checks of LAL mattresses weekly to ensure proper functioning.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents with wounds to ensure all orders have been processed and treatments are being done correctly.
- R2's mattress was replaced with a new mattress.