Failure to Prevent and Treat Pressure Ulcers Resulting in Severe Wound Complications
Penalty
Summary
A deficiency occurred when the facility failed to implement and monitor interventions, treatments, and assessments necessary to prevent and manage pressure ulcers for a resident at risk. The resident, who had diagnoses including muscle weakness and diabetes mellitus, was dependent on staff for mobility and personal care and was identified as being at risk for pressure ulcers. Despite this, documentation shows that staff did not consistently assess, report, or initiate timely treatment for new wounds, specifically on the resident's sacrum and right ear. Initial signs of skin breakdown were documented, but no treatment orders were initiated for several days, and there was a lack of communication among staff and with the facility's provider and DON regarding the resident's condition. Multiple staff interviews revealed that several CNAs and nurses observed significant wounds on the resident's coccyx and right ear, but these findings were not promptly or adequately reported or addressed. Nursing documentation was inconsistent, with some assessments failing to note the presence of wounds, and some staff not following up on abnormal findings. The facility's care plan and skin management policy required regular assessments and prompt notification of new skin impairments, but these protocols were not followed. The resident's wounds worsened, and there was a delay in both provider assessment and the initiation of appropriate wound care treatments. As a result of these failures, the resident developed unstageable pressure ulcers on the sacrum and right ear, which progressed to infection, sepsis, and required hospitalization. The sacral wound ultimately led to osteomyelitis and gangrene, necessitating surgical intervention. Interviews with facility leadership confirmed a lack of awareness and oversight regarding the resident's wounds, and documentation review showed that required notifications and interventions were not completed in accordance with facility policy.
Plan Of Correction
F686 Treatment/Services to Prevent/Heal Pressure Ulcer Resident #3 readmitted to the facility on 4/17/25. Skin assessment completed: Stage 4 pressure to sacrum and healed pressure injury to right ear. Care plan updated and currently being followed by the wound certified NP. Residents who reside in the facility have the potential to be affected. Skin sweep completed. Any concerns were addressed immediately. Nursing staff re-educated on Skin Management program. Those currently on leave of absence or PRN will be re-educated on their next scheduled workday. Skin Management policy was reviewed by QA committee and deemed to be appropriate. The DON and/or designee will review Clinical Alerts, PCC dashboard, physician orders, and complete skin assessments weekly x 4, then monthly x 3. Concerns will be addressed immediately and findings will be reported to the QA committee for further review and recommendations. Administrator is responsible for sustained compliance.