Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a significant pressure ulcer in a resident, failed to ensure wound dressings were maintained as ordered, and did not complete accurate or timely skin assessments. The resident, who had diagnoses including failure to thrive, dysphagia, and major depressive disorder, was initially documented as having intact skin. However, within a week, an unstageable pressure ulcer measuring 25x10 cm developed on the resident's sacrum. Despite the presence of risk factors such as hypertension, anemia, poor appetite, bowel and urinary incontinence, and malnutrition, not all risk factors or potential interventions were documented or addressed in the facility's investigation report. Nursing documentation was inconsistent and incomplete, with a weekly skin assessment incorrectly stating the resident's skin was intact even after the pressure ulcer had developed. No further weekly skin observations were recorded after this incorrect entry. Staff interviews revealed uncertainty about when the wound was discovered and acknowledged that the required weekly skin assessments and documentation were not completed as expected. The wound care nurse and DON confirmed that the skin assessment documentation was inaccurate and that the wound should have been described and monitored. Direct observation showed that the resident's wound was not covered with a dressing as ordered by the physician, and staff confirmed that a dressing should have been present. The wound care nurse and other staff stated that if a dressing is missing, it should be reported and reapplied, but this did not occur. The facility's own pressure ulcer policy outlines regular skin inspections, timely repositioning, and the use of pressure-reducing devices, but these measures were not consistently implemented or documented for this resident.