Failure to Implement Comprehensive Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer program, resulting in the development and worsening of pressure ulcers for two residents. One resident, who was cognitively impaired, dependent on staff for activities of daily living, and at high risk for skin breakdown, was admitted with a Stage III pressure ulcer to the sacrum and a Stage IV ulcer to the left knee. There was a lack of proper assessment, monitoring, and intervention to prevent further decline. The resident's sacral ulcer deteriorated to a Stage IV with infection and osteomyelitis, with contributing factors including missed and duplicate treatment applications, missed antibiotic doses, and a lack of effective pressure-reducing interventions. Documentation revealed multiple missed wound care treatments, incomplete or inaccurate orders, and failure to consistently implement preventive measures such as turning, repositioning, and barrier cream application. Staff interviews revealed that wound care orders were not always accurately transcribed or implemented, and that key staff, including the LPN responsible for wound care and the DON, lacked formal wound care training. There were also lapses in communication between the wound care provider, nursing staff, and medical director, resulting in continued use of outdated or inappropriate wound care orders. The resident did not receive consistent monitoring of vital signs or daily skilled charting while on antibiotics, and there was a delay in transferring the resident to the hospital despite evidence of wound deterioration and infection. A second resident, also cognitively impaired and dependent on staff, was identified as being at moderate risk for skin breakdown. This resident developed a right lateral ankle wound that was not classified or consistently assessed. Weekly skin assessments were missed for multiple weeks, and preventive interventions such as heel floating and turning/repositioning were not consistently implemented or documented. Observations confirmed that the resident was not turned or had heels floated as required, and the wound was later identified as a Stage III pressure ulcer. Facility policy required weekly wound measurements and documentation, which was not followed for either resident.