Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
A facility failed to prevent the development of an avoidable, facility-acquired, unstageable pressure injury in a resident who was admitted with intact skin on the sacrococcyx area. The resident, who had a history of post laminectomy syndrome, spinal cord disease, kidney cancer, and bone tumor, was dependent on staff for toileting and bathing and required assistance for turning and repositioning. Despite physician orders and facility policy requiring repositioning every two hours, documentation showed multiple shifts where the resident was not turned or repositioned as required. The resident's care plan and physician orders specified the need for turning and repositioning every two hours, as well as regular checks for incontinence. However, facility records indicated that on at least fourteen occasions, staff failed to turn and reposition the resident during entire shifts. There was no documentation explaining these omissions, nor was there evidence that staff updated the care plan or documented any refusals of care by the resident, as required by facility policy. Interviews with staff revealed that some believed the resident refused to be woken for repositioning, but this was not communicated to nursing staff or documented in the medical record. As a result of these failures, the resident developed a stage 2 pressure injury on the sacrococcyx, which deteriorated to an unstageable wound and ultimately to a stage 4 pressure injury after debridement at an acute care hospital. The wound became infected, delaying further medical treatment for the resident's underlying conditions. Family members reported that staff did not consistently reposition the resident or provide necessary padding when the resident was in a wheelchair, and that the resident required assistance and reminders to change position due to loss of sensation in the lower body.