Failure to Identify, Treat, and Prevent Worsening of Pressure Ulcer
Penalty
Summary
A resident with a history of pressure ulcers, paraplegia, urinary tract infection, and osteomyelitis was admitted to the facility with existing Stage Four pressure ulcers on the right ischium and left knee. The resident was identified as high risk for developing additional pressure ulcers and was dependent on staff for bed mobility, toileting, dressing, and required maximum assistance with bathing and personal hygiene. Despite these risk factors, the facility failed to promptly identify and treat a newly acquired sacral pressure ulcer, which was first documented as a Stage Two ulcer and rapidly progressed to Stage Four with significant necrotic tissue. There was a delay in obtaining and implementing physician orders for the sacral ulcer, as the wound was identified on 4/7/25 but treatment orders were not entered into the electronic medical record until 4/11/25. During this period, no treatment was provided for the sacral ulcer, and the care plan was not updated to reflect the new wound. The wound nurse acknowledged forgetting to obtain and implement the necessary dressing orders, and communication between floor nurses and the wound nurse regarding the new wound was lacking. Documentation confirmed that no treatment was provided for the sacral ulcer prior to the entry of orders. Observations revealed that the resident was not consistently provided with pressure-relieving interventions, such as off-loading with pillows or blankets, despite facility policy requiring dependent residents to be turned and positioned approximately every two hours. Staff interviews indicated that residents, including the affected individual, often waited longer than two hours to be repositioned due to staffing constraints. The resident experienced significant pain associated with the sacral ulcer, particularly during dressing changes, and was observed without appropriate off-loading devices in place.