Failure to Prevent and Timely Treat Pressure Ulcer
Penalty
Summary
A facility failed to identify and prevent the development of a pressure ulcer for one resident, resulting in the formation of a left heel pressure ulcer. The resident, who has a history of diabetes, dependence on renal dialysis, and polyneuropathy, was found to have an unstageable pressure ulcer with necrotic tissue and moderate drainage. The resident reported not being aware of the ulcer until it was discovered by a nurse, and expressed concern due to a previous amputation related to a non-healing pressure ulcer. Documentation revealed that the dressing was not changed daily as ordered, with a missed treatment noted on the treatment administration record. The wound was observed to have a dressing dated two days prior, and the wound nurse practitioner performed wound care during the surveyor's observation. The resident's care plan identified a risk for pressure ulcers due to impaired mobility, but the Braden Scale assessment did not indicate risk, and the Minimum Data Set did not document a pressure ulcer. Facility policy requires routine skin assessments and immediate reporting of any developing pressure injuries, but the pressure ulcer was not identified until it had already developed. The facility's failure to consistently assess, document, and provide timely wound care contributed to the development and progression of the pressure ulcer.