Failure to Prevent and Properly Manage Pressure Ulcer in Resident with Contracture
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis, and multiple contractures was admitted to the facility and developed a pressure ulcer (PU) on the left hand, specifically between the thumb and index finger. The resident was identified as being at high to moderate risk for skin breakdown based on Braden Scale assessments. Despite this, there was no care plan developed to address the risk of pressure ulcer development for the left contracted hand, nor were interventions such as splinting or range of motion exercises included in the care plan to prevent further contracture or promote healing. When the pressure ulcer was first identified, a wound evaluation was not completed as required by facility policy. The lack of timely wound assessment meant that the interdisciplinary team (IDT) was not made aware of the new wound, as the evaluation is necessary for the wound to appear on the report reviewed during IDT meetings. Additionally, the facility was not conducting IDT meetings for residents with wounds unless there was also weight loss, resulting in no IDT review of this resident's wound. The care plan for the pressure ulcer was also missing key interventions for pressure relief and did not reflect the interventions listed in the Skin & Wound evaluation. Observations and interviews confirmed that the care plan did not include interventions to maintain clean skin or prevent further breakdown, and the contracture care plan lacked range of motion or splinting interventions. The information about wound care and contracture management was not communicated to CNAs via the Kardex, and there was no documentation of discussions with hospice staff regarding the contracture. The hospice nurse also did not include interventions for skin breakdown or contracture prevention in their documentation. These omissions resulted in the development of a pressure ulcer on the resident's left thumb and had the potential to prolong healing.