Failure to Provide Timely Wound Care and Maintain Preventative Devices
Penalty
Summary
The facility failed to maintain proper wound care for two residents. For one resident with multiple complex diagnoses, including a sacral pressure ulcer, a Certified Nurse Practitioner ordered a referral to a wound clinic and laboratory tests for a comprehensive metabolic panel. However, the facility did not follow through with these orders, as the referral was not made and the laboratory tests were not obtained. This was confirmed by both the practitioner and the Regional Director of Clinical Operations, and wound documentation later showed the presence of an unstageable pressure ulcer. For another resident with diabetes, chronic kidney disease, and polyneuropathy, the care plan required the use of heel protector boots while in bed to prevent skin breakdown. Despite this, the resident was observed in bed without the boots, which were found lying against the wall. The resident stated the boots should have been on, and this was verified by an LPN present at the time, who acknowledged the boots should have been in use.