Failure to Identify, Report, and Treat New Pressure Ulcer in High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure ongoing assessment and monitoring for a resident with a history of pressure ulcers, resulting in a new, unreported stage 2 pressure ulcer on the sacral area. The wound was discovered during a surveyor's observation, not by facility staff, despite the resident being at high risk for skin impairment due to multiple medical conditions including chronic kidney disease, heart failure, Parkinson's disease, dementia, and incontinence. The wound care nurse and wound care coordinator were not aware of the new open wound, and there was no recent documentation of wound assessments in the resident's medical record since the previous year. The facility did not follow its own pressure ulcer prevention and skin assessment policies, which require daily skin inspections, prompt reporting of changes, and timely notification of the physician and family. The charge nurse and LPN were unaware of the new wound, and the certified nursing assistant (CNA) did not report the skin breakdown. The wound care coordinator and wound nurse continued to provide daily treatments to the sacral area without documenting weekly skin assessments or identifying the new pressure ulcer. Additionally, the facility failed to implement preventive measures as outlined in its policy, such as providing a specialty mattress for the resident, who was at high risk for pressure injuries. The specialty mattress was not provided until after the surveyor raised concerns. The physician was not notified in a timely manner for appropriate wound treatment orders, and the care plan was not updated to reflect the new pressure ulcer.