Failure to Accurately Assess Pressure Ulcer and Improper Foley Catheter Management
Penalty
Summary
A resident with a history of cord compression and a benign neoplasm of the pituitary gland was admitted with limited mobility and a moderate risk for pressure ulcers, as indicated by a Braden Scale score of 13. Despite this risk, there was no care plan in place to address the potential for pressure ulcer development. When a wound was identified on the resident's coccyx, the treatment nurse initially assessed it as a skin tear, despite the presence of thin skin and a darkened area. Two days later, a wound physician correctly identified the wound as a stage 2 pressure ulcer. Nearly four weeks later, the wound had progressed to a stage 4 pressure ulcer. The director of nursing confirmed that the initial assessment was incorrect and that no care plan had been developed for pressure ulcer prevention or management. Additionally, the resident had a foley catheter that was changed from size F16 to F18 without a written physician's order. The nurse practitioner verbally communicated the change, but the order was not properly documented, and the previous order for the F16 catheter was not discontinued. This resulted in both catheter sizes being listed in the treatment administration record, causing confusion among licensed nurses regarding which size to use. The resident expressed concern about staff competency in managing the foley catheter, and the director of nursing acknowledged the lack of proper documentation and order management.