Failure to Identify and Document Pressure Ulcer Led to Advanced Wound
Penalty
Summary
Facility staff failed to consistently assess and document changes in the skin condition of a resident who was totally dependent on staff for all activities of daily living due to quadriplegia and other significant medical conditions. The resident was identified as being at risk for pressure ulcers and had care plans and physician orders in place for regular skin assessments, use of pressure-reducing devices, and frequent repositioning. Despite these interventions, there was no documented evidence of any skin integrity issues with the resident's left foot in the progress notes or treatment administration records for an extended period. The deficiency was identified when a licensed practical nurse discovered a wound on the resident's left foot, which was subsequently assessed by a wound care nurse practitioner and determined to be a Stage 3 pressure injury. The wound was described as having significant tissue involvement, with exposed subcutaneous tissue and moderate serosanguineous exudate. Interviews with staff confirmed that regular head-to-toe skin assessments were documented as completed, but the pressure ulcer was not identified until it had progressed to an advanced stage. Further investigation revealed that the resident's left foot had been pressing against the bed's footboard, likely contributing to the development of the pressure injury. The lack of timely identification and documentation of the skin breakdown, despite ongoing documentation of completed assessments and interventions, resulted in actual harm to the resident.