Failure to Timely Identify and Treat Pressure Ulcer Resulting in Actual Harm
Penalty
Summary
The facility failed to timely identify, assess, and provide appropriate interventions for a resident at high risk for pressure ulcers, resulting in the development and progression of an unstageable pressure ulcer. The resident, who had quadriplegia, anemia, diabetes mellitus, and diabetic neuropathy, was dependent on staff for all aspects of care and was identified as being at risk for skin breakdown. Despite care plan interventions for skin monitoring and pressure relief, there was no documentation of skin breakdown or wound measurements for a significant period, and the first physician order for wound care was delayed. When a wound was first noted, there was insufficient documentation regarding its size, appearance, and treatment, and no specific physician order for wound care was in place for several weeks. Progress notes indicated inconsistent and incomplete wound assessments, with gaps in documentation and lack of timely communication with the physician. The wound was not properly measured or described until it had progressed to an unstageable pressure ulcer with 100% slough, requiring surgical debridement. The facility's own policy required weekly monitoring and documentation of wounds, which was not followed. Interviews with staff and review of medical records confirmed that there was a lack of timely and accurate assessment, documentation, and intervention for the resident's pressure ulcer. The physician was unaware of the wound and had not provided orders for its care during the critical period. The resident ultimately required multiple hospitalizations, surgical debridement, and a diverting colostomy due to the progression and complications of the wound. The failure to follow established guidelines and facility policy resulted in actual harm to the resident.