Failure to Prevent and Accurately Document Facility-Acquired Stage 4 Pressure Ulcer
Penalty
Summary
A resident with paraplegia, hypertension, and a history of stroke was admitted and later readmitted to the facility. The resident, who was cognitively intact, developed a Stage 4 pressure ulcer on the right ischium while in the facility. The care plan included daily skin checks by CNAs and reporting of abnormalities to nursing staff. However, documentation inconsistencies were noted, including a skin assessment that failed to record any new wounds despite the presence of a pressure ulcer. The treatment administration record showed the application of antifungal cream for a rash, but there was no documentation of wound care for the pressure ulcer during that period. Wound evaluations documented the progression of the pressure ulcer, initially identified as unstageable and later as Stage 4, with ongoing notes indicating the wound was stable or improving. The resident reported that prolonged use of a motorized wheelchair may have contributed to the wound's development. During interviews, the DON was unable to explain discrepancies in documentation and acknowledged that the wound could not have developed in a single day. The facility's policy required thorough assessment and documentation of pressure sores, but these protocols were not consistently followed, resulting in the resident acquiring a facility-acquired Stage 4 pressure ulcer.
Plan Of Correction
F 686 1.) Resident #80 was reassessed by the nurse manager for pressure ulcer prevention to ensure treatments were appropriate and the care plan was updated. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all skin alterations were identified and preventative measures were in place. Licensed nurses and CENAs were re-educated on preventive skin measures, accuracy of completing skin assessments, and documentation. 3.) System change: Nurse managers will witness 5 skin assessments weekly with the nurse to ensure accuracy. Any new areas identified will be documented in the skin assessment. 4.) DON/Designee will audit 5 charts weekly x 12 weeks then monthly x 3 months to ensure appropriate preventive measures are in place, and will complete 5 random skin assessments to ensure accuracy. Any nonadherence will result in 1:1 education. All audits will be taken to the QA committee for review and further recommendations. The DON is responsible for ongoing and sustained compliance.