Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of pressure ulcers and to provide care consistent with professional standards for a resident who was admitted without wounds but later developed multiple pressure injuries. The resident, who had significant risk factors including impaired mobility, contractures, dementia, and other comorbidities, was dependent on staff for all activities of daily living. Despite being identified as high risk for skin breakdown, early signs of pressure injuries, such as a blood blister and bruising on the right foot and discoloration on the left hip, were not adequately monitored or addressed. Documentation shows that initial findings were reported by hospice staff and noted in weekly skin assessments, but interventions were limited to the application of barrier creams and skin prep, without escalation or timely wound care consultation. The facility did not consistently perform or document weekly skin assessments as required by policy, with at least one missed assessment and delayed recognition of worsening skin conditions. When new or worsening wounds were identified, such as the open area on the left hip and necrotic wounds on the right foot and toe, there was a lag in obtaining wound care consultations and implementing appropriate treatment orders. Communication gaps were evident, as the wound care nurse was not promptly informed of changes, and the responsible party was not always notified about new or worsening wounds. The care plan and interventions were not updated in a timely manner to reflect the resident's changing condition. Interviews with staff revealed a lack of clarity regarding roles and responsibilities for skin monitoring and wound care, with reliance on CNAs and charge nurses to identify and report issues, but without a robust system to ensure follow-up and escalation. The wound care nurse became involved only after significant deterioration had occurred, and the wound care physician confirmed that the wounds had been present and worsening for more than five days before surgical intervention. The facility's failure to monitor, assess, and respond to early signs of pressure injuries resulted in the resident developing multiple advanced-stage pressure ulcers.