Failure to Assess, Document, and Treat Pressure Ulcer Leads to Wound Deterioration
Penalty
Summary
A resident with multiple diagnoses, including Alzheimer's Disease, Parkinson's Disease, diabetes, and vascular dementia, was found to have developed a pressure ulcer while under the care of the facility. The resident was completely dependent on staff for mobility and personal care, requiring regular turning and repositioning. Despite a certified nursing assistant (CNA) observing a reddened area on the resident's buttocks and verbally reporting it to a nurse, there was no documentation or formal wound assessment completed at that time. The CNA continued to apply barrier ointment and turn the resident, but the initial signs of skin breakdown were not formally recorded or addressed in the medical record. The wound care nurse later confirmed that the area was red and classified it as a superficial Stage 1 pressure injury but did not document an assessment. The wound care nurse was then absent on vacation, and the wound was not reassessed or documented until a hospice nurse identified a new pressure ulcer on the sacrum several days later. The wound was initially coded incorrectly in the Minimum Data Set (MDS) and was not properly staged or documented as a deep tissue injury. Treatment orders for the wound were not consistently entered into the Treatment Administration Record (TAR), and some prescribed treatments were missing from the record, making it unclear whether they were administered as ordered. The facility's own policies required full assessment and documentation of pressure sores, including location, stage, and measurements, as well as ensuring physician orders for wound care procedures. These protocols were not followed, resulting in a lack of timely and accurate documentation, incomplete treatment records, and a failure to implement effective interventions to prevent further deterioration. As a result, the resident's pressure ulcer progressed to an unstageable wound requiring debridement.