Failure to Prevent and Manage Pressure Ulcers Due to Missed Assessments and Treatments
Penalty
Summary
The facility failed to implement and document new care plan interventions to prevent new or worsening pressure ulcers for a resident with multiple risk factors, including diabetes, peripheral vascular disease, and immobility. The staff did not consistently complete skin assessments, ensure the availability of wound care supplies, or perform wound treatments as ordered. As a result, the resident developed a stage II pressure ulcer on the right buttock, a stage III pressure ulcer on the left buttock, and experienced worsening of an existing right heel wound, which required antibiotic treatment. These wounds were discovered by a nurse practitioner during rounds, not by facility staff, indicating a lack of timely identification and intervention. Observations and record reviews revealed that the resident was left in a wheelchair for extended periods without adequate repositioning, and incontinent care was delayed, as evidenced by a full brief with bowel movement upon being returned to bed. Documentation showed repeated lapses in wound care, with multiple entries indicating that treatments were not completed due to unavailable supplies or lack of documentation. There were also missed or delayed skin assessments, including after hospital readmission, and no evidence that new wounds were promptly identified or addressed by staff. Behavioral tracking did not indicate that the resident refused care or treatments during the relevant period. Interviews with facility leadership and clinical staff confirmed expectations that nurses should follow up on treatment changes, document assessments, and notify supervisors if supplies are lacking. However, the nurse practitioner and administrator acknowledged that these processes were not followed, and new wounds were only discovered during external wound care rounds. The facility's own policy required regular skin inspections, timely repositioning, and the use of appropriate pressure-relieving equipment, but these measures were not consistently implemented for the resident in question.
Removal Plan
- Facility pressure ulcer prevention policy was reviewed by President of Operations and was found to be in compliance with state and federal regulations.
- R1 was seen by Wound Care Provider and received new treatment orders, LAL (low air loss) mattress ordered, and wheelchair cushion replaced.
- Director of Nursing or designee initiated in-servicing for all facility and Agency nursing staff to include RNs, LPNs and CNA's, on the pressure ulcer prevention policy and procedures.
- In-servicing will be completed by the start of each staff member's next shift.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on pressure ulcer prevention.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant to ensure that all newly acquired pressure wounds are identified timely and addressed immediately by reviewing shower sheets daily and ensuring all skin assessments are completed timely and thoroughly.
- Director of Nursing or designee will in-service all facility and Agency nursing staff to include RNs, LPNs and CNA's on identifying all newly acquired pressure areas timely by completing assessments timely and accurately.
- All nursing staff will be educated by the beginning of their next shift.
- Director of Nursing or designee will conduct audits of skin assessments weekly to ensure all new skin conditions are identified timely and addressed accurately as part of the QA process.
- The Director of Nursing or designee will interview 3 staff members weekly x4 weeks to ensure that staff are completing assessments and addressing any new pressure areas.
- Director of Nursing and or designees will conduct skin assessments on all to ensure that any pressure areas are being identified and addressed.
- The staff members responsible for not completing assessments or wound treatments as ordered have been disciplined.
- The DON or designee will review all new admissions to ensure that all assessments are completed.
- The DON or designee educated all facility and agency nurses of how and when to complete skin assessments.
- All facility and agency nurses will be educated by the beginning of their next shift.
- R1 has had a full skin assessment performed by the ADON to ensure all areas of concern have been identified and addressed appropriately.
- All facility and Agency nursing staff to include RNs, LPNs and CNA's, educated by DON or designee that all residents need to be turned and repositioned at least every two hours and as needed.
- All in-servicing will be completed by the beginning of the staff member's next scheduled shift.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents to determine if they are at risk for potential for impaired skin integrity.
- IDT team ensured all skin assessments have been done timely, all new skin areas have been identified and addressed accordingly including care plan review.