Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident admitted with a pressure ulcer on the coccyx. Upon admission, the resident was noted to have a non-blanchable purple wound on the coccyx, but the staff did not accurately assess the wound, including taking measurements or providing a description. Furthermore, the staff failed to notify the physician to obtain and implement treatment orders. This lack of action resulted in the pressure ulcer becoming unstageable with necrosis, requiring surgical intervention. The resident, who had diagnoses including spinal stenosis, cord compression, malignant neoplasm of bone, and protein-calorie malnutrition, was dependent on two-assist for activities of daily living. Despite being at risk for skin breakdown, the facility did not conduct proper wound assessments or document the condition of the pressure ulcer from the time of admission until it was evaluated by a wound physician. The wound was not treated or monitored adequately, leading to its deterioration. The facility's documentation and treatment protocols were not followed, as evidenced by the lack of wound assessments and physician notifications. The wound was only properly assessed and treated after it had significantly worsened, necessitating excisional debridement surgeries. The facility's policies required accurate documentation and timely interventions, which were not adhered to in this case, resulting in actual harm to the resident.
Plan Of Correction
Immediate Actions Taken: On 3-11-25, the treatment nurse conducted a skin assessment on Resident #43. At this time, the wound was measured, staged, documentation completed, and wound doctor notified. Treatment continued per order. CP was reviewed to ensure all appropriate interventions were in place. Identification of like residents having the potential to be affected: Skin assessments were completed for all residents by 03-12-25 by the nursing management team. No new wounds were identified. Actions taken/systems put into place to reduce the risk of future occurrences included: The treatment nurse was provided education on or before 3-12-25 by the DON related to the expectation to conduct a 2nd skin check on all new admissions within 48 hours of admission and to ensure all skin checks are completed weekly. All direct care staff was educated on or before 3-24-25 by DON/Designee regarding Pressure Injury Prevention, completing a full skin assessment on admission and ongoing weekly, timely reporting of newly discovered skin alterations, and ensuring interventions/treatments are in place. 100% compliance was achieved, as evidenced by a signed attestation. Ongoing Monitoring: The treatment nurse will audit all admission skin assessments and ongoing weekly skin assessments, interventions/treatments, and notifications as required for completeness weekly x 4 weeks and monthly x 3 months and as needed thereafter. The DON/designee will also complete audits to ensure the treatment nurse is completing 2nd skin assessments within 48 hours of a newly admitted resident by auditing one admission weekly x 4 weeks, monthly x 3 months, and prn thereafter. The DON/designee will audit 3 random residents' weekly skin assessments for completeness and accuracy weekly x 4 weeks, monthly x 3 months, and prn thereafter. Findings will be reviewed by the QAPI Committee until such a time consistent substantial compliance has been achieved as determined by the committee.