Failure to Implement Wound Care Recommendations and Repositioning Protocols
Penalty
Summary
Facility staff failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. For one resident, staff did not implement wound nurse practitioner recommendations for treatment of a right heel and a right anterior lower leg pressure injury. The wound nurse practitioner recommended specific treatments, such as skin prep for the right heel and various wound dressings for the lower leg injury, but these were not entered into the physician orders or the electronic treatment administration record (eTAR) in a timely manner. Observations confirmed that staff were unaware of any treatment in place for the right heel, and documentation showed a delay in implementing recommended treatments for the lower leg wound. Another resident experienced a worsening pressure injury due to the facility's failure to change treatment as recommended by the wound nurse practitioner. The resident was totally dependent on staff for turning and positioning, yet the recommended wound care was not implemented for an extended period. Documentation revealed that the prescribed frequency of wound care was not followed, and the wound increased in size during this time. Additionally, staff failed to turn and reposition the resident as required, with observations and interviews confirming that the resident was left in the same position for several hours and did not receive the necessary assistance overnight. A third resident with a stage 4 sacral pressure ulcer did not receive the wound nurse practitioner's recommended changes in wound care, including the use of medical grade honey fiber and dual antibiotic coverage for a suspected infection. The facility continued with an outdated treatment regimen, and documentation showed that turning and positioning tasks were not performed on multiple nights. The resident's wound worsened, with increased depth and slough, and the recommended interventions were not implemented prior to the resident's discharge to the hospital.