Failure to Provide Ordered Care for Facility-Acquired Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care for a facility-acquired Stage 3 pressure ulcer on a resident’s left buttock. The resident had multiple diagnoses, including paranoid schizophrenia, type 2 diabetes, hypertension, muscle wasting/atrophy, and unsteadiness on feet, and had Braden scores indicating they were at risk for pressure injury. The care plan documented the need for repositioning/ambulation at least every two hours, substantial/maximal staff assistance with ADLs, incontinence care after each episode, and minimizing pressure over bony prominences with treatment as ordered. Physician orders and the TAR directed that the left buttock wound be cleansed with wound cleanser, treated with silver sulfadiazine, and covered with a gauze dressing daily and as needed. The facility’s wound report and wound evaluation summaries documented that the Stage 3 pressure ulcer was facility-acquired and provided measurements and characteristics of the wound, including moderate serous drainage and significant slough. On observation, CNAs transferred the resident with a mechanical lift and found the incontinence brief soiled with urine, but they did not perform perineal care, did not apply a dressing to the left buttock wound, and instead placed a clean brief and pulled up the resident’s pants before returning the resident to the wheelchair without the ordered dressing. The resident’s bed did not have a pressure-redistribution mattress, despite the resident spending increased time in a wheelchair and having a facility-acquired Stage 3 pressure ulcer. Staff confirmed during interviews that the resident did not have a dressing on the left buttock at the time of observation, and the wound physician and administrator acknowledged that the pressure ulcer was acquired in the facility. The facility’s own skin condition and pressure injury policy required that dressings be dated by the licensed nurse, checked daily for placement and cleanliness, that care plans be revised to reflect skin alterations and approaches, and that physician-ordered treatments be recorded after each administration, but these requirements were not followed for this resident’s pressure ulcer care.
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