Failure to Implement Pressure Ulcer Prevention and Wound Healing Interventions
Penalty
Summary
The facility failed to provide appropriate care and services to promote wound healing and prevent the worsening of pressure injuries for one resident. The resident, who was admitted with multiple diagnoses including radiculopathy, vertebrogenic low back pain, spinal fusion, and Type II Diabetes Mellitus, was identified as having a stage I pressure injury on the sacrococcyx upon admission. Despite being at moderate risk for pressure injuries according to the Braden Scale, the care plan interventions were limited to notifying the physician if the ulcer failed to heal and providing offloading of the ulcer site. There was no evidence that a low air-loss mattress or nutritional supplements such as zinc, vitamin C, or a multivitamin were implemented, even though these interventions were indicated in the facility's policies and were recognized by staff as beneficial for wound healing. Over the course of the resident's stay, the pressure injury progressed from stage I to stage II with a deep tissue injury, as documented in skin assessments. Interviews with staff revealed that the treatment nurse would typically request a wound consult and supplements if a wound worsened to stage II, but no such orders were placed for this resident. The dietary assistant manager confirmed that no vitamin C or zinc orders were present and stated that these should have been recommended. The primary physician also acknowledged that ordering vitamin supplements would have been beneficial for the resident's wound healing, given the presence of a pressure injury upon admission. Further review of facility policies indicated that residents with wounds should receive a comprehensive nutritional assessment and appropriate interventions, including recommendations for supplements and specialized mattresses. However, the registered dietitian was not present during the initial assessment to provide recommendations, and the necessary interventions were not implemented. Family members also expressed concern that the resident was not being turned regularly, which may have contributed to the worsening of the wound. The facility's failure to follow its own policies and to implement recognized interventions resulted in the resident's pressure injury worsening during their stay.