Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents with significant skin integrity issues. One resident with moderate cognitive impairment and total dependence on staff for care had a Stage II pressure ulcer on the right buttocks and an unstageable ulcer on the left heel. Despite physician orders for a Mepilex dressing to be applied and changed every three days, the resident was observed without the required dressing, and staff acknowledged the omission. Documentation showed inconsistencies, with the treatment marked as completed earlier that day, but the dressing was not present during the observation. The resident's history included recent hospitalization for pneumonia, UTI, and pressure injuries, with conflicting accounts from facility staff regarding the presence of wounds prior to hospital transfer. Another resident, also with moderate cognitive impairment and multiple comorbidities including malnutrition and COPD, had a Stage IV pressure ulcer on the sacrum. This resident was bedfast, incontinent, and dependent on staff for all mobility and hygiene. During care observations, staff failed to document and measure three additional areas of skin breakdown on the resident's legs, and the primary wound dressing was found to be soiled, undated, and improperly removed by a CNA rather than a nurse. The wound was left open during a shower and exposed to a soiled lift sling, contrary to best practices. Review of treatment records revealed multiple missed or undocumented wound care treatments as ordered by the physician. Facility policy required daily and weekly wound documentation and monitoring for residents with impaired skin integrity, but this was not consistently followed. The lack of proper documentation, failure to apply and maintain ordered dressings, and missed wound care treatments contributed to the deficiency. The facility did not ensure that residents with pressure ulcers received necessary care to promote healing, prevent infection, and prevent new sores from developing, as required.