Failure to Prevent and Timely Treat Facility-Acquired Stage III Pressure Ulcer
Penalty
Summary
A facility failed to operationalize its policies and procedures for skin and wound assessments and treatments, resulting in the development and worsening of a facility-acquired Stage III pressure ulcer for a resident. The resident, who had significant cognitive impairment, limited mobility, incontinence, and other comorbidities such as diabetes and Alzheimer's disease, was dependent on staff for most activities of daily living. Despite these risk factors, documentation showed that the resident did not have a pressure ulcer at the time of a recent assessment, but a new Stage III ulcer was identified later without timely assessment or intervention. There was a lack of timely wound assessment and treatment following the initial identification of the pressure ulcer. The wound was first identified on one date, but the first documented assessment by the wound care nurse occurred two days later. There was no documentation of wound care or dressing changes until several days after the wound was identified. Additionally, the physician and the resident's representative were not notified until several days after the wound was discovered. The care plan was not promptly updated with new interventions specific to the newly developed wound, and existing interventions lacked measurable details, such as specific repositioning intervals or air mattress settings. Observations revealed that the resident's pressure-relieving equipment, such as the wheelchair cushion, was in poor condition and had not been replaced in a timely manner. During a dressing change, improper technique was observed, including adhesive from the dressing being placed over the open wound bed and the presence of fecal matter in the wound area. Staff interviews confirmed gaps in documentation, assessment, and communication regarding the wound, as well as delays in updating care plans and implementing appropriate interventions.
Plan Of Correction
1. Resident #4 resides in the facility. It was identified that the resident's wound was in fact a Kennedy Ulcer, and the resident has been placed on hospice for additional support. 2. Like residents are identified as those with a Braden scale of 16 or less. A sweep was completed on 3/17/25 of all current residents to assess their current Braden scale. Like resident's medical records were reviewed between 3/17 through 3/20/25 to ensure their plan of care includes appropriate interventions for prevention of skin breakdown. All future residents admitted with a Braden score of 16 or lower will have appropriate interventions implemented in their plan of care timely. 3. The Policy on Skin Management has been reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on appropriate process for initiating timely interventions upon admission and with any change of condition between 3/13 and 3/20/25. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure interventions for skin prevention are initiated timely upon admission or any change of condition. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review. Date of Compliance 3/27/2025