Failure to Assess, Document, and Intervene for Pressure Ulcers
Penalty
Summary
A resident with a history of dementia, major depressive disorder, and chronic obstructive pulmonary disease was admitted to the facility from an inpatient psychiatric hospital. Upon admission, the resident was assessed as not being at risk for pressure ulcers and had no current skin impairments. However, over the course of her stay, the resident developed significant skin issues, including large blisters on both heels and eventually a pressure injury to the coccyx. Despite changes in her mobility, increased incontinence, and the development of pressure injuries, the care plan was not updated to reflect these changes or to include new interventions as recommended by wound care specialists and as indicated by skin assessments. The facility failed to consistently document and assess the resident's wounds. Although wound care consultations and recommendations were made, such as the use of heel protectors, barrier creams, and turning protocols, these were not always incorporated into the care plan or consistently documented in the medical record. There was also a lack of detailed wound measurements and descriptions, particularly regarding the coccyx wound, and no evidence that the wound nurse practitioner was notified of the open area on the coccyx. Orders for wound treatments were given, but staff interviews revealed confusion about the presence and treatment of the coccyx wound, and the wound was not properly tracked or communicated. Upon discharge to another facility, the resident was found to have an extensive, unstageable pressure injury to the coccyx with foul odor and slough, as well as black wounds on both heels. The receiving facility and the resident's family were unaware of the extent of the wounds prior to transfer. Documentation from the sending facility did not accurately reflect the resident's wound status at discharge, and there was no indication that the care plan had been updated to address the new and worsening wounds. The lack of timely assessment, documentation, and individualized interventions led to the worsening of the resident's pressure injuries.