Failure to Timely Identify and Treat Pressure Injuries and Surgical Wounds
Penalty
Summary
The facility failed to timely identify and treat the development of pressure injuries for a resident who was at moderate risk due to limited mobility and required assistance with repositioning. Upon admission, the resident had no pressure wounds on the coccyx, and skin assessments confirmed the absence of such wounds in the following weeks. However, the resident later developed an open wound on the buttocks, which was not identified or reported until it had progressed to a stage 2 pressure injury. Multiple certified nursing assistants confirmed that the resident could not reposition independently and did not refuse assistance, and one CNA reported noticing redness but could not recall to whom it was reported. The facility also failed to consistently provide prescribed treatments for the resident's existing surgical wounds on the right foot and knee. Treatment administration records showed several missed treatments for the resident's surgical sites, including post-amputation and wound vacuum therapies. Interviews with licensed nurses revealed that, due to the absence of a dedicated treatment nurse, medication nurses—who lacked formal wound management training—were responsible for wound care. These nurses reported being overwhelmed with multiple duties, making it unlikely that all treatments were administered as ordered. As a result of these lapses, the resident's surgical wounds did not heal properly, became infected, and ultimately led to further amputations. The director of nursing confirmed that the expectation was for CNAs to report skin changes promptly and for licensed nurses to ensure timely assessment and treatment, which did not occur in this case. The facility's policy emphasized the importance of structured risk assessment and individualized care planning, but these procedures were not effectively implemented for this resident.