Failure to Prevent and Manage Pressure Ulcers Under Immobilizers and Inadequate Wound Assessment
Penalty
Summary
The facility failed to properly identify, assess, intervene, and treat pressure wounds for three residents, resulting in the development of facility-acquired unstageable wounds, particularly under immobilizers. According to the facility's own policy, daily skin checks and prompt reporting of skin changes are required, but these procedures were not consistently followed. For one resident, a pressure ulcer developed on the right calf under an immobilizer, and the wound nurse confirmed that the immobilizer was not removed for daily skin checks. Additionally, the same resident had an undocumented wound on the buttock that the wound nurse was unaware of, indicating a breakdown in communication and documentation. Another resident was admitted with a deep tissue injury on the right buttock, which remained unchanged in size for several weeks according to wound assessments. However, on observation, the wound was found to be larger and covered with slough, and the wound nurse applied zinc paste directly to the wound without a physician's order or notification of the wound's change in condition. The first treatment order for this wound was not obtained until several days after the wound's deterioration was observed, demonstrating a delay in appropriate intervention and physician notification. A third resident, who was dependent on staff for activities of daily living and assessed as high risk for pressure ulcers, developed a facility-acquired pressure ulcer on the right lower extremity under a leg immobilizer. Physician orders required skin checks under the immobilizer every shift, but the treatment administration record showed multiple days where these checks were not documented, despite the resident being present in the facility. The wound nurse admitted to not reviewing the treatment record for compliance with skin checks and was unaware of missed documentation, further contributing to the failure to prevent and manage pressure ulcers as required.