Delay in Pressure Ulcer Identification and Treatment
Penalty
Summary
A resident with severe cognitive impairment, diabetes, and incontinence was identified as being at risk for pressure ulcers and had a care plan in place to minimize skin exposure to moisture and to monitor and report changes in skin status. Despite these interventions, the resident was repeatedly observed wearing wet clothing and lying on wet bedding with a strong odor of urine, indicating prolonged exposure to moisture. Staff failed to provide timely incontinence care, as the resident's wet clothing remained unchanged over several hours during multiple observations. On one occasion, staff observed an open area on the resident's buttock, but there was no documented evidence that a medical provider was notified or that any treatment was initiated for three days. The resident's medical and treatment records showed no documentation of skin impairment or treatment during this period. Interviews with staff revealed inconsistent accounts of when the skin breakdown was first noticed and whether it was reported to nursing staff. Some CNAs stated they notified a nurse, while others could not recall which nurse was informed. The nurse manager and the Director of Nursing were not made aware of the skin breakdown until days later. When eventually assessed by a nurse practitioner, the resident was found to have two stage 2 pressure ulcers. The facility's policy required daily skin inspections, prompt reporting, and documentation of changes, but these procedures were not followed. The delay in notification and initiation of treatment resulted in actual harm to the resident, as the pressure ulcers were not addressed in a timely manner.