Failure to Prevent and Treat Pressure Ulcers Resulting in Immediate Jeopardy
Penalty
Summary
A resident with a history of stroke, hemiplegia, malnutrition, diabetes, and other comorbidities was identified as high risk for pressure ulcer development, with a Braden score of 12. The resident was dependent on staff for mobility, repositioning, and personal care, and was frequently incontinent. Despite these risk factors, documentation and interviews revealed that staff failed to consistently and thoroughly assess, document, and report changes in the resident's skin condition. Weekly skin assessments were incomplete, often performed without fully removing clothing, and relied heavily on nursing assistants' observations rather than direct nurse assessment. There was a lack of detailed documentation regarding the size, appearance, and progression of skin issues, and communication gaps existed between nursing staff, nurse managers, and providers. Multiple staff members, including nursing assistants and LPNs, observed wounds developing on the resident's sacral area and heel, but these findings were not promptly or adequately reported to the provider or wound care team. The resident did not consistently have a pressure-relieving cushion in her wheelchair, and interventions such as repositioning and use of barrier creams were inconsistently documented. When wounds were noted, there was confusion about who was responsible for notifying the provider and initiating treatment. The resident's care plan directed staff to monitor skin integrity daily, perform weekly skin inspections, and report changes, but these interventions were not effectively implemented or documented. The resident was eventually found unresponsive and sent to the hospital, where she was diagnosed with multiple advanced pressure ulcers, including a large necrotic sacral wound, deep tissue injury to the heel, and additional skin breakdowns. Hospital staff noted that the wounds were extensive and had developed over several weeks, indicating a prolonged period of inadequate care. Interviews with facility staff and hospital personnel confirmed that the wounds were present prior to hospital admission and that there were significant lapses in assessment, reporting, and treatment of the resident's skin issues.