Failure to Provide Timely Pressure Ulcer Care Resulting in Wound Infection and Hospitalization
Penalty
Summary
A resident with multiple medical conditions, including a displaced femur fracture, muscle weakness, diabetes, and existing pressure ulcers, was admitted to the facility with documented wounds on the coccyx and both heels. Despite being identified as at risk for further skin breakdown, the resident did not receive a wound assessment or wound care orders from admission until eight days later. During this period, there was no wound care nurse available for approximately one week, and the resident's wounds were not assessed or treated. Facility staff confirmed that the resident did not have wound care orders until the delayed assessment, and the Director of Nursing was unaware of this lapse. Following the delayed intervention, the resident's wounds deteriorated, with the sacral wound becoming infected, as evidenced by wound cultures and physician assessments. The resident subsequently developed sepsis, was transferred to the hospital, and was diagnosed with acute metabolic encephalopathy likely due to sepsis from the sacral wound infection. Facility policy required consistent monitoring and documentation of wounds, but this protocol was not followed, resulting in a decline in the resident's condition.