Failure to Follow Wound Clinic Orders and Provide Consistent Pressure Injury Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure injury care and treatment to promote healing and prevent worsening of existing pressure injuries for one cognitively intact resident with multiple comorbidities, including CHF and type 2 diabetes. Upon admission, the resident had a stage 2 sacral pressure injury (identified by the facility as coccyx) and a deep tissue injury (DTI) on the left heel. Admission wound clinic documentation emphasized that offloading was of utmost importance, directing that the resident be turned side-to-side every two hours, not lie directly on the sacrum, and that an alternating pressure mattress be initiated as soon as possible if the sacral wound progressed. The same documentation instructed that the left heel DTI be kept covered with a protective border dressing and that heel boots be used at all times to float the heels off the mattress. Subsequent wound assessments documented that the coccyx/sacral wound worsened over several weeks, progressing from a stage 2 to a stage 3 pressure injury with increasing size and development of slough and eschar, yet the medical record contained no indication that an alternating air mattress was ordered despite the wound clinic’s recommendation tied to wound progression. The left heel DTI also increased in size and changed in character, with notes indicating the wound had worsened or was larger and darker, and orders were in place for daily dressing changes and continuous use of heel boots or heel-floating. Treatment Administration Records for January and February showed multiple missed wound treatments for both the coccyx and left heel, as well as missed repositioning and heel-floating opportunities, despite the care plan interventions to reposition the resident at least every two hours and keep heels floated or in heel boots at all times. During surveyor observations on multiple occasions, the resident was found in bed on a regular pressure-relieving mattress rather than an alternating air mattress, without heel boots in place, and with both heels in contact with the mattress and footboard. The left heel dressing was dated six days prior, although orders required daily dressing changes. The resident reported generally accepting wound care and heel boots when offered and did not indicate frequent refusals. Nursing staff acknowledged that the heel dressing had not been changed on the observed shift because it was not assigned, and the Wound RN confirmed that the heel dressing was overdue for change and that the resident’s heels should have been floated with heel boots or pillows. The Wound RN also stated that the wound clinic note with the alternating mattress recommendation had not been reviewed prior to survey, and there was no documentation that an alternating air mattress had been obtained during the period when the wound was documented as worsening.
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