Missed Weekend Wound Care for Resident With Multiple Pressure Injuries
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatments to a resident with multiple pressure injuries over a weekend. The resident was an elderly male with severe cognitive impairment (BIMS score of 2) and a diagnosis of MRSA infection, who was admitted with multiple pressure injuries, including Stage 3 and unstageable ulcers on the left hip, right gluteal fold, sacrum, left buttock, and both ankles. His care plan and wound evaluation documented specific daily treatment orders for each wound, including cleansing with normal saline or wound cleanser, application of Santyl or collagen, use of Hydrofera Blue, and coverage with bordered gauze or foam dressings, to be done daily and as needed for soiling or dislodgement. Record review of the resident’s electronic treatment administration record (eTAR) for December showed no documentation that any wound care was provided on the Saturday and Sunday in question, despite daily treatment orders. The resident reported that he received wound care Monday through Friday but not on the weekend. When the wound care nurse returned the following Monday, she observed that the resident still had the same dressings in place that she had applied on the prior Friday, indicating that the weekend treatments had been missed. Interviews with staff confirmed that weekend wound care was not completed. The ADON who worked that weekend acknowledged she knew the resident had multiple wounds and that she was responsible for performing wound care because the treatment nurse did not work weekends, but stated she missed the treatments, left early both days, and did not inform the relieving nurses that wound care had not been done. The wound care nurse stated that weekend staff were supposed to provide the treatments and that she did not notify management, expecting them to review treatment records. The ADON and DON both stated they were responsible for ensuring MARs/TARs were checked and that they had not reviewed the wound care TAR for this resident. The wound care NP stated that nurses or the wound care nurse were supposed to follow the treatment orders and that missing treatment placed the resident at risk for infection and worsening wounds.
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