Failure to Provide Timely Pressure Ulcer Assessment and Intervention
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and treat pressure injuries for one resident, resulting in the development and progression of pressure ulcers. The resident, who had a history of major depressive disorder, dementia, hemiplegia, hemiparesis, and was dependent on staff for all activities of daily living, was identified as being at risk for pressure ulcers. Despite this, timely assessment and intervention were not provided after new wounds were discovered. Specifically, there was a delay in updating the care plan and implementing interventions such as an air mattress, Broda chair, and pain management, which were only added after the wounds had already developed and worsened. The facility did not provide timely wound care orders or notify key individuals, including the wound care provider and hospice, when new wounds were identified. For example, a deep tissue injury (DTI) to the resident's left heel was documented by the wound care provider, but no wound care orders were in place until several weeks later, after the issue was brought to the facility's attention during the survey. Similarly, a stage 2 pressure ulcer on the coccyx progressed to a stage 3 ulcer before the wound care provider was notified and appropriate interventions were implemented. Documentation also revealed inconsistencies in repositioning records, with the resident being left on his back for several hours on multiple days, despite being at high risk for pressure injuries and requiring frequent repositioning. Staff interviews confirmed that the resident was dependent on staff for repositioning and did not refuse care, contradicting claims that refusals contributed to the development of wounds. There was also a lack of thorough and accurate wound care documentation, and delays in notifying the physician and obtaining wound care orders. The facility's failure to follow its own policies and procedures for skin integrity assessment, timely intervention, and communication with the care team contributed to the resident's pressure injuries worsening.