Failure to Prevent and Timely Identify Pressure Ulcer at PEG Tube Site
Penalty
Summary
Facility A failed to prevent the development of a facility-acquired pressure ulcer in one resident who was at risk, as identified through interviews, record reviews, and policy review. The resident, who had severe cognitive impairment and diagnoses including palliative care, stroke, and gastrostomy status, was admitted with no open skin areas documented in weekly skin assessments. However, wound care documentation later identified a Stage II pressure injury at the PEG tube site, which was not detected until it had progressed to that stage. The facility's policy required skin inspections every shift, especially under medical devices, but the pressure ulcer was not identified during routine care or weekly assessments. Interviews with staff revealed that the pressure ulcer was discovered only after a note was left for the wound care nurse to examine the area under the PEG tube's plastic bumper. It was found that no gauze or foam was placed under the bumper, which is considered standard care, although not explicitly required by facility policy. The DON acknowledged that proper gastrostomy care, including the use of gauze or sponge, is covered during orientation and is standard practice. The administrator recognized the need for proper skin checks and adherence to policy and standards, but the deficiency occurred due to the failure to identify and prevent the pressure ulcer in a timely manner.