Failure to Ensure Competent Wound Care and Timely Notification for Pressure Ulcer
Penalty
Summary
The facility failed to ensure that nursing staff, specifically the Wound Care Nurse (LVN), possessed and demonstrated the appropriate competencies and skill sets necessary to provide adequate nursing care and maintain resident safety and well-being. The Wound Care Nurse identified a Stage 2 pressure ulcer in a resident but did not follow facility policy regarding notification of changes to the RN Unit Manager or designee. Documentation showed that required notifications to the practitioner, resident/responsible party, dietician, and therapy services were left blank on multiple wound evaluation forms. The Wound Care Nurse was unable to recall if or when the physician was notified and admitted that documentation of such notification was not completed. The resident involved had a complex medical history, including sepsis, metastatic cancer, severe malnutrition, dysphagia, muscle wasting, and incontinence, placing him at high risk for skin breakdown and pressure injuries. Despite these risks, the care plan and physician orders for pressure reduction and skin protection were not adequately supported by timely and appropriate communication regarding the development of a new pressure ulcer. The NP Wound Nurse, who was responsible for wound care oversight, was not notified or referred the case, and upon review, stated that the resident should have been referred for further evaluation and management. Interviews with facility staff revealed confusion regarding the scope of practice for the Wound Care Nurse, particularly in relation to wound staging and notification protocols. The Wound Care Nurse had completed wound care certification but was unclear about the training received on wound staging and the requirement to notify appropriate clinical staff upon identification of a pressure ulcer. The facility's policy required notification of the attending physician upon identification of a new pressure injury, but this was not followed, and there was no documentation of physician notification or subsequent clinical actions. This lapse in competency and communication directly affected the resident's care and could have impacted his health outcomes.