Failure to Conduct Weekly Skin Observations and Timely Pressure Ulcer Treatment
Penalty
Summary
Facility staff failed to conduct weekly skin observations and timely evaluations for a resident with severe cognitive impairment, Alzheimer's disease, and diabetes mellitus, who was at high risk for pressure ulcers and dependent on staff for bed mobility. The resident's care plan required frequent repositioning, regular skin inspections during care, and prompt notification of new skin conditions. Despite these requirements, weekly skin observation records showed significant gaps, with no new skin impairments documented over several weeks, and a 35-day lapse between observations during which a new, unstageable pressure ulcer developed on the resident's coccyx. A hospice bath aide first noted an open sore on the resident's bottom, and hospice staff left a handwritten note for facility staff regarding the new wound. However, the note was not acted upon, as the responsible nurse was absent and did not ensure the information was communicated to oncoming staff. Progress notes and interviews revealed that a wound dressing order was placed but not implemented, and there was no prior written order for a dressing. The facility's investigation confirmed a breakdown in the skin/wound management process and a lack of nurse follow-up regarding treatment orders. Interviews with staff indicated that the hospice provider discovered the wound before facility staff did, and that required weekly skin observations and documentation were not completed as per protocol. The delay in identifying and treating the pressure ulcer resulted from missed observations, lack of communication among staff, and failure to follow up on treatment orders, leading to inadequate evaluation and delayed care for the resident's pressure ulcer.