Failure to Prevent and Manage Pressure Ulcers Due to Inadequate Incontinence Care and Communication
Penalty
Summary
A resident with multiple complex medical conditions, including atrial fibrillation, diabetes, and cognitive impairment, was admitted to the facility and assessed as being at risk for pressure injuries. Upon admission, initial nursing assessments documented intact skin with no wounds or discoloration. However, within days, a treatment nurse identified purplish discoloration on the resident's sacrum, and wound care was initiated. Documentation and interviews revealed inconsistencies regarding whether the sacral wound was present on admission or developed shortly after, with some staff stating the wound was not present at admission and others indicating it was. The resident was dependent on staff for activities of daily living, including toileting and incontinence care, and was always incontinent of bowel and occasionally of bladder. On one occasion, a CNA failed to provide timely incontinent care, leaving the resident soiled for an extended period. This lapse was observed by the resident's family member, who reported the resident's bed and clothing were saturated with feces and urine. The CNA later admitted to not checking the resident's care plan and relying on incorrect information from another CNA regarding the resident's continence status. The nurse on duty was made aware of the situation and ensured the resident was changed, but the incident was not promptly escalated to facility leadership. Subsequently, the resident developed an open sacral wound and later a new left heel wound, both of which were documented as acquired in-house. The care plan did not initially address all aspects of the resident's ADL care, and there were gaps in communication and documentation regarding wound care and skin assessments. The failure to provide consistent and timely incontinence care, along with inadequate communication among staff regarding the resident's needs and care assignments, contributed to the development and progression of pressure injuries.