Failure to Prevent and Manage Pressure Ulcer Progression
Penalty
Summary
A resident who was admitted with intact skin on the sacrum developed a Stage III pressure ulcer that progressed to a Stage IV, with healing ultimately not achievable. The resident was dependent on staff for all care needs and had a history of medical co-morbidities, increasing the risk for pressure ulcers. Although interventions such as an air mattress, repositioning, use of a wedge, and a cushion in the wheelchair were implemented, documentation showed that repositioning every two hours was not consistently performed or recorded. The care plan specified limited time in a wheelchair and frequent repositioning, but these interventions were not reliably documented or executed. Wound care documentation was inconsistent, with measurements and identification of undermining and tunneling not reliably recorded. Dressing changes ordered by the physician were missed on multiple occasions, as evidenced by gaps in the treatment administration records. The wound was identified as infected at one point, and the resident received several courses of antibiotics for wound infection and cellulitis. However, the care plan did not specify the location or severity of the wound, and interventions for pain management prior to wound treatments were not consistently documented, despite the resident refusing some treatments due to pain. Staff interviews indicated that the resident occasionally refused repositioning, but staff generally believed the resident did not frequently refuse care. There was a lack of consistent documentation regarding refusals and pain management interventions. The combination of missed repositioning, incomplete wound care documentation, missed dressing changes, and insufficient pain management contributed to the failure to prevent the development and worsening of the pressure ulcer.