An Iowa nursing home was fined $9,000 after failing to treat a pressure ulcer that contributed to the death of a resident. According to state records, the woman was admitted to the facility on October 4 with a stage II pressure ulcer on her backside. However, the initial care plan did not include a turning or repositioning program and instead labeled the resident as independent in terms of mobility.
On October 10, a nurse noted that the wound had increased in size and was emitting a foul odor. The nurse later told state inspectors that she should have conducted a more thorough assessment and informed the resident’s doctor, but she did neither.
By October 15, less than two weeks after admission, the resident was transferred to a hospital emergency room with sepsis. At that point, the wound had worsened to the point where a nurse practitioner described it for inspectors as “shocking.”
The resident died on October 18, with sepsis related to the untreated wound listed as a contributing factor. Her primary physician reportedly told inspectors that the wound could have been avoided or minimized if the staff had informed her of the resident’s condition.
Compliance Perspective
Issue
According to F686 in the State Operations Manual Appendix PP, based on the comprehensive assessment of a resident, facilities must ensure that a resident receives care consistent with professional standards of practice to prevent pressure ulcers. A resident should not develop pressure ulcers unless their clinical condition demonstrates that they were unavoidable. Additionally, a resident with pressure ulcers must receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing.
Discussion Points
- Review policies and procedures related to the prevention, treatment, and healing of pressure ulcers. Ensure that these policies include the involvement of a qualified wound care provider when necessary.
- Provide staff with training on the identification of abuse and neglect, as well as protocols to prevent the development of pressure ulcers. In addition, educate staff on proper wound care to facilitate healing of existing wounds. Conduct annual competency evaluations of staff to assess their ability to perform wound care and implement preventive measures. Offer additional training where necessary to maintain standards of care.
- Periodically audit care processes to ensure that protocols for preventing and treating pressure ulcers are in place and are being followed. Review care plans to ensure they include appropriate goals and interventions related to both the prevention of pressure ulcers and the treatment of existing wounds.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
