Failure to Accurately Assess and Manage Pressure Ulcer Leading to Hospitalization
Penalty
Summary
The facility failed to accurately assess and manage a sacral/coccyx wound for a resident with dementia, gastrostomy, dysphagia, and total dependence on staff for activities of daily living. The initial wound assessment documented a new open area on the coccyx, but the wound was incorrectly described as moisture-associated skin damage (MASD) rather than a pressure injury, despite clinical findings consistent with a Stage 3 pressure wound. There was no documentation of the facility identifying the wound in weekly skin assessments, nor were adequate and appropriate interventions implemented in the care plan to prevent wound development. Over the following days, the facility did not identify the worsening of the wound or notify the physician of the resident's declining condition. The resident developed abnormal vital signs, altered mental status, and was eventually transferred to the hospital, where the wound was debrided and identified as a Stage 4 pressure ulcer with associated sepsis. The facility's records did not show timely recognition of the wound's deterioration or appropriate communication with the physician prior to the resident's hospitalization.