Failure to Identify and Assess Pressure Ulcers Resulting in Actual Harm
Penalty
Summary
The facility failed to thoroughly assess and monitor the skin condition of a resident who was admitted with a stage IV sacral pressure ulcer and multiple high-risk factors, including impaired cognition, dependence on staff for activities of daily living, and a history of pressure ulcers. Despite these risks, the facility did not complete a pressure ulcer risk assessment until over two weeks after admission, and licensed nurses did not perform documented skin checks during this period. Certified Nursing Assistant (CNA) documentation indicated no new skin issues, and the wound nurse and wound nurse practitioner did not identify any wounds on the resident's right shoulder during wound rounds conducted one week prior to the discovery of a new ulcer. On a subsequent wound round, the wound nurse and wound nurse practitioner discovered an unstageable pressure ulcer with slough and necrotic tissue on the resident's right shoulder, which had not been previously identified or documented. The wound was covered with an undated Xeroform gauze dressing, and facility staff were unable to determine when the wound developed or who applied the dressing. The lack of timely and thorough skin assessments, as well as the absence of communication and documentation regarding new skin issues, contributed to the pressure ulcer progressing to an advanced stage before it was detected. Facility policy and national guidelines require prompt identification of at-risk residents and implementation of interventions to prevent pressure ulcers, as well as ongoing comprehensive skin assessments. In this case, the facility did not follow these standards, resulting in actual harm to the resident, who developed a new, advanced-stage pressure ulcer that was not identified until significant tissue damage had occurred.