Failure to Prevent and Treat Pressure Ulcers Resulting in Worsening Wounds and Hospitalization
Penalty
Summary
The facility failed to provide adequate care and services to prevent and promote healing of pressure ulcers for three residents, resulting in worsening wounds, infections, and hospitalizations. All three residents were dependent on staff for all care and were identified as high risk for skin breakdown. The facility did not consistently implement or document required interventions such as turning and repositioning, and there were multiple missed wound treatments as evidenced by gaps in the Treatment Administration Record (TAR) and CNA task documentation. For example, one resident had 42 eight-hour shifts without documented turning and repositioning, and 20 missed wound treatments for facility-acquired pressure wounds. Another resident had 23 eight-hour shifts without documented repositioning and four missed wound treatments for a worsening coccyx pressure wound. A third resident had 37 eight-hour shifts without documented repositioning and 21 missed wound treatments for pressure wounds, with incomplete turning logs maintained by family members as further evidence of lapses in care. The residents involved had significant medical histories, including traumatic brain injury, cerebral vascular accident, acute respiratory failure, and comatose states, making them highly susceptible to pressure injuries. Despite care plans and physician orders specifying frequent turning, repositioning, and wound care, these interventions were not reliably carried out or documented. Wound assessments showed progression of pressure ulcers from initial stages to unstageable or stage 4, with some wounds developing slough, odor, and signs of infection. In several cases, the wounds deteriorated to the point of requiring hospital transfer for advanced wound management, debridement, and treatment of sepsis or osteomyelitis. Interviews with staff confirmed that documentation was incomplete and that staffing shortages contributed to the inability to provide required care. Unit managers and wound nurses acknowledged that there were holes in the TAR and CNA documentation, and that some wound treatments were not recorded as completed. Staff also reported that, at times, there were not enough CNAs to turn residents every two hours as required by care plans. There was no evidence provided by the facility to demonstrate that the worsening or facility-acquired pressure ulcers were unavoidable, despite the presence of appropriate interventions in the care plans.
Plan Of Correction
Element 1 Resident 105 no longer resides in the facility and was discharged to the hospital on 3/26/25. Resident 106 no longer resides in the facility and was discharged to the hospital on 4/1/25. Resident 111 continues to reside in the facility. Her wounds, treatment orders, and care plans were reviewed by the Director of Nursing, Wound Nurse, and wound care provider by 4/25/25 and deemed to be appropriate. An unavoidable assessment was completed due to the resident's wound being expected to decline on admission due to comorbidities and assessment of periwound. Element 2 A skin sweep of current residents was completed by the Director of Nursing/Designee by 4/25/25 for any new skin areas. Any new areas noted were assessed, had treatment orders entered, and care plans updated for interventions to prevent and promote healing of wounds. A one-time audit of current residents with wounds was completed to ensure the wounds have appropriate treatment orders and interventions to prevent and promote healing of wounds. This was completed by the Director of Nursing/Designee by 4/25/25. A one-time audit of residents' most recent Braden score was completed, and anyone with a Braden score of 10 or below was placed on the yellow dot program for turning and repositioning. Element 3 The QAPI Committee has reviewed the Pressure Ulcer Prevention and Management policy and has deemed it to be appropriate by 4/25/25. The Director of Nursing and/or designee educated the Wound Care Nurse and the licensed nurses on the Pressure Ulcer Prevention and Management policy by 4/25/25, with emphasis on the yellow dot program for turning and repositioning, ensuring wound treatments are being completed, and appropriate interventions are in place to prevent and promote healing of wounds. Nurse Aides were educated on the yellow dot program for turning and repositioning and checking the resident kardex to ensure interventions are in place. This was completed by the Staff Development Coordinator/Designee by 4/25/25. Wounds will be reviewed daily in the morning clinical Monday through Friday to ensure treatments are being completed and weekly in the standard of care meeting to ensure appropriate interventions are in place to prevent and promote wound healing. Element 4 The Director of Nursing/designee will audit residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure interventions are in place and treatments are being completed to prevent and promote healing of wounds. The Director of Nursing/designee will audit residents with a Braden score of 10 or less weekly for 4 weeks, then monthly thereafter, to ensure they are being turned and repositioned appropriately to prevent and promote healing of wounds. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible for maintaining compliance.