Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with multiple comorbidities, including end stage renal disease, diabetes, cognitive impairment, and immobility, was admitted to the facility with a high risk for skin breakdown and existing pressure wounds. Initial assessments did not identify wounds on the coccyx or right flank, and the admission MDS did not document the presence of stage 3 or unstageable pressure injuries, nor did it include interventions such as pressure-reducing devices, a turning/repositioning program, or nutrition/hydration measures. However, within days, new wounds were identified, including a stage 2 wound on the right rear flank and a stage 3 wound on the coccyx, which were not present or documented at admission. Observations and interviews revealed that the resident was not consistently turned or repositioned, especially while in bed or in a wheelchair, despite being at high risk for pressure injuries. Staff, including CNAs and therapy personnel, expressed a belief that offloading cushions alone were sufficient and that repositioning was not necessary when such devices were used. There was no scheduled turning or repositioning program in place, and the care plan only included general interventions such as turning and repositioning as needed. The resident was observed sitting on an obstructed offloading cushion and without offloading support for the right flank wound, and staff confirmed that no specific offloading or repositioning was provided for that area. Further, wound assessments were inconsistent and not promptly communicated to clinical leadership or the physician. The presence of black tissue in the right flank wound, indicating an unstageable wound, was not documented as a significant change in condition, and neither the physician nor the physician's assistant were made aware of this development. The wound team had not seen the wound for at least a week, and there was a lack of clear communication and documentation regarding the resident's wound status and necessary interventions.