Failure to Prevent and Manage Pressure Ulcers Resulting in Wound Deterioration
Penalty
Summary
A resident with a history of left femur fracture, joint replacement surgery, and type 2 diabetes was admitted to the facility with existing wounds, including a left heel blister and a right heel suspected deep tissue injury (SDTI). Upon admission, the facility failed to document comprehensive wound assessments, including descriptions and measurements of the wounds. The initial skin integrity check did not provide adequate baseline information, and subsequent weekly wound assessments were not documented as required by facility policy. The left heel blister was reclassified as an SDTI three days after admission, but this change was not communicated to the physician, and the care plan was not updated in a timely manner to reflect the new wound status or necessary interventions. The facility did not implement or consistently provide essential interventions to prevent the progression of the resident's wounds. The resident did not consistently receive offloading measures such as heel protector boots or a low air loss mattress, and nutritional supplements to promote wound healing were not initiated until much later. The interdisciplinary team, including the DON, treatment nurse, and registered dietician, did not meet to discuss or coordinate care for the resident's wounds. The resident was not referred to a wound care practitioner despite the presence of worsening wounds, and the physician was not notified when the left heel blister was reclassified as an SDTI or when the wound developed signs of infection, including foul odor, eschar, and slough. As a result of these failures, the resident's left heel blister and right heel SDTI progressed to unstageable pressure injuries, causing significant pain and requiring transfer to an acute care hospital for further management. The resident received intravenous antibiotics, pain management, and hydration in the emergency department. Interviews with staff and family members confirmed lapses in wound care, documentation, communication, and timely intervention, all of which contributed to the decline in the resident's condition.