Failure to Assess and Monitor Pressure Ulcer Resulting in Worsening Condition
Penalty
Summary
The facility failed to comprehensively assess, monitor, and provide appropriate interventions for a resident who developed a pressure ulcer, resulting in the progression of a stage 2 pressure ulcer to a stage 3. The resident, who had a history of edema and was at risk for pressure injuries, initially developed a small stage 2 ulceration on the right medial 4th toe. Podiatry provided specific wound care orders, including keeping the foot dry and maintaining the dressing, but documentation shows that these orders were not consistently followed. The treatment administration record indicated that the daily wound care order was discontinued after only one day, and there was no documentation that the wound had healed at that time. Nursing staff interviews revealed a lack of consistent wound assessment and monitoring. LPNs and RNs could not recall the specifics of the wound care provided, and there was confusion about the location and status of the ulcer. Weekly skin checks were reportedly performed, but staff admitted to not always checking between the toes, where the ulcer was located. The resident's care plan and facility policies required regular assessment and documentation of wounds, but there was no evidence of wound assessment or measurement for several months. The wound was eventually found to have deteriorated to a stage 3 pressure ulcer with significant slough and maceration, and the podiatrist noted that the wound had worsened since the initial evaluation. Communication failures were also evident, as the medical doctor had not received updates on the wound's status between the initial and follow-up evaluations. Staff interviews indicated that the wound was not consistently reported or documented, and there was no clear protocol for monitoring the wound after it was considered healed. The director of nursing confirmed that there was no documentation of the wound being healed and that a scabbed wound would not be considered healed. Facility policies required evidence-based wound care and ongoing assessment, but these were not followed, leading to the resident's pressure ulcer worsening.