Failure to Provide Ordered Pressure Ulcer Treatments and Maintain Negative Pressure Wound Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered pressure ulcer treatments and services to promote healing and prevent new pressure sores for two residents with significant skin breakdown. For one resident with a seizure disorder and metabolic encephalopathy, admission assessments and an MDS indicated a sacral pressure sore and multiple deep tissue injuries present on admission. The care plan identified actual skin breakdown with an intervention for staff to provide treatments as ordered. Physician orders directed specific wound care to multiple sites (sacrum, right and left hips, left and right lower back, lower spine, and right plantar foot), including cleansing with normal saline, application of Santyl, Medihoney, skin prep, betadine-moistened gauze, packing with saline-moistened gauze, and covering with bordered foam or gauze dressings on the evening shift. Review of the Treatment Administration Records for this resident showed no evidence that any of the ordered wound treatments were completed on multiple specific dates in December, January, and March. These missed treatments involved all ordered wound sites, indicating that the facility did not follow the physician’s wound care regimen as required by its own wound management policy, which states that the physician or wound consultant determines appropriate treatment and staff are to follow the physician’s orders and product instructions. There was no documentation to show that the ordered cleansing, packing, and dressing applications were carried out on the identified dates. For another resident with multiple sclerosis and a sacral pressure ulcer, a wound care note and MDS documented a sacral pressure sore, cognitive intactness, and total dependence on staff for care. The care plan included interventions for staff to provide treatments as ordered and to reposition the resident in bed. Physician orders required application of black foam and a negative pressure wound therapy (NPWT) dressing connected to a vacuum pump set at 125 mmHg continuously, with dressing changes three times weekly and checks of placement and function every shift. The TAR contained no documented evidence that the NPWT treatment was functioning during several shifts. Observations showed the resident lying flat on her back with the bed flat, the wound pump turned off and disconnected, and the resident reporting that the pump had not worked since the previous afternoon and that staff did not reposition her. Further observation confirmed she remained flat in bed without repositioning, and the DON acknowledged there was no documentation that the treatments for one resident or repositioning and NPWT for the other had been completed as ordered.
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