Failure to Document and Communicate Significant Pressure Ulcer Changes
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent the worsening of pressure ulcers for one resident. Specifically, staff did not assess and document detailed observations using the SBAR (Situation, Background, Assessment, Recommendation) communication tool when there were significant changes in the resident's skin and wound conditions on the left trochanter and sacral areas on multiple occasions. These changes in wound size and condition were not communicated through the required SBAR process, as confirmed by interviews with the wound treatment nurse, registered nurse supervisor, infection preventionist nurse, and director of nursing. The facility's policy required that significant changes in a resident's condition, such as those observed in wound size and severity, be documented and communicated using SBAR to ensure timely interdisciplinary review and care plan revision. The resident involved was an 84-year-old female with a history of encephalopathy, essential hypertension, and pulmonary embolism, who was admitted with multiple pressure ulcers and altered mental status. The resident was assessed as being at risk for developing pressure ulcers and was dependent on staff for several activities of daily living. Despite documented changes in the size and severity of stage 4 pressure ulcers on the left trochanter and sacrococcyx, there was no evidence that these changes were communicated using the SBAR tool or that a change of condition form was initiated as required by facility policy. Interviews with facility staff revealed a lack of awareness and follow-through regarding the responsibility to initiate SBAR communication for significant wound changes. The wound treatment nurse, who was new to the position, was unaware of the resident's wounds and did not initiate SBAR documentation. The infection preventionist nurse and director of nursing both confirmed that the observed changes in wound size were significant and should have triggered SBAR communication and care plan review, but this did not occur. The facility's own policy outlined the need for detailed observation and communication for significant changes, which was not followed in this case.