Failure to Provide Consistent Assessment and Appropriate Treatment for Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new pressure ulcers for two residents with actual or potential pressure injuries. Facility policy required that residents with pressure injuries or at risk for skin breakdown receive weekly body audits by licensed staff, with pressure injuries assessed and documented at least weekly, including location, measurements, stage, drainage, odor, and detailed description of the wound bed, edges, and peri-wound area. For one resident admitted with dementia and muscle weakness and an existing Stage 3 pressure ulcer, the record showed physician orders for weekly skin assessments on a specific shift, and treatment administration records documented that skin checks were completed on several dates. However, the corresponding weekly body audits did not include the required detailed assessment elements for the Stage 3 pressure injury on multiple dates. Further review of this resident’s wound care showed that the contracted wound physician initially recommended daily treatment of a left lateral heel Stage 3 pressure ulcer with normal saline cleansing, Silvadene (SSD), and a silicone dressing, and a physician’s order was entered to that effect. A subsequent wound physician progress note revised the recommendation to daily cleansing with normal saline, application of A & D ointment, and leaving the wound open to air, and a new physician’s order was entered reflecting this change. The clinical record did not show that the original Silvadene order was discontinued, and treatment administration records indicated that both Silvadene and A & D ointment were administered to the same heel wound for a period of 16 days, contrary to the wound physician’s revised recommendation. During interview, the nurse practitioner stated that her expectation was that the Silvadene would have been discontinued when the A & D treatment was ordered. For a second resident readmitted with dementia, hemiplegia and hemiparesis following a stroke, a quarterly MDS assessment identified the resident as at risk for developing pressure ulcers. Weekly body audits documented a skin check with no skin impairment on one date in December, but there was no evidence of any weekly skin check from that date through early January. A Pressure Injury Evaluation form completed in mid-January identified a newly developed Stage 2 pressure area on the coccyx. Subsequent weekly body audits completed later in January did not document the required detailed assessment of this Stage 2 pressure injury, including location, measurements, drainage, odor, or description of the wound bed, edges, and peri-wound area, and one audit failed to identify any skin impairment at all. In interview, the DON stated that her expectation was that weekly skin checks be completed and that any pressure area be fully assessed and documented with the required elements.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.