Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
A resident with multiple comorbidities, including diabetes, impaired mobility, and a history of limb amputation, was admitted to the facility and identified as being at risk for pressure ulcers based on Braden Scale assessments. Upon admission and readmission, the resident had skin issues such as scrotal excoriation, for which barrier cream was ordered, but the care plan did not reflect this intervention. The resident required extensive assistance with mobility and was always incontinent of bowels, further increasing the risk for skin breakdown. Documentation revealed that the resident was on a turning and repositioning program, but CNA documentation only showed repositioning tasks for AM and PM, and there was no evidence of consistent implementation or monitoring of these interventions. Over the course of the resident's stay, multiple pressure ulcers developed and worsened, including unstageable wounds to the sacrum and left ischial areas, as well as moisture-associated skin damage (MASD) to the buttocks. Progress notes and wound nurse documentation indicated that the provider and responsible party were not always notified promptly when new wounds or changes occurred. The care plan was not updated in a timely manner to reflect the presence of new or worsening wounds, offloading interventions, or the use of a mattress overlay, despite these being ordered and discussed in clinical notes. There were also discrepancies between physician orders and what was transcribed or implemented in the treatment administration record (TAR), such as the use of iodosorb and the frequency of dressing changes. Interviews with staff revealed inconsistent practices regarding skin assessments, documentation, and communication. CNAs reported that skin issues were to be reported to nurses during showers, but documentation in the shower log did not consistently note skin issues. The wound nurse and NP confirmed that the resident was non-compliant with repositioning, but the care plan for refusal to turn was not initiated until after significant wound progression. Ultimately, the resident's sacral wound deteriorated, developing undermining and possible fistula formation, leading to transfer to the hospital for further evaluation and treatment. The facility failed to ensure timely and comprehensive care planning, consistent implementation of pressure ulcer prevention interventions, and prompt provider notification, resulting in the development and worsening of pressure ulcers.