Failure to Monitor and Intervene for Worsening Pressure Ulcer
Penalty
Summary
A deficiency occurred when staff failed to monitor and intervene appropriately as a resident's pressure ulcer worsened. The resident, who had multiple diagnoses including diabetes, anemia, and immobility, was identified as being at risk for skin breakdown and pressure injuries. The care plan included assistance with incontinence care but did not specify interventions for repositioning. The resident was found to have excoriation on the sacrum, and an order for zinc oxide was initiated. However, there was no documented monitoring, measurement, or further description of the wound from the time it was first identified until ten days later, during which time the wound deteriorated significantly. During this period, the only documented treatment was the application of zinc oxide, with no evidence of wound assessment or escalation of care as the condition worsened. The facility's policy required daily skin monitoring and prompt reporting of abnormal findings, as well as implementation of interventions such as turning and repositioning, but there was no documentation that these were consistently performed. The resident's wound progressed from excoriation to an unstageable pressure ulcer with eschar, and later to a stage 4 ulcer with exposed bone, infection, and osteomyelitis. The low-air-loss mattress, a key intervention, was not ordered until 18 days after the initial wound was documented. Interviews with the DON revealed a lack of awareness regarding the absence of wound monitoring and treatment orders during the critical period. The DON confirmed that there was no documentation of regular turning and repositioning, and that the electronic medical record did not have a designated place for such documentation. No root cause analysis was conducted to determine why the pressure ulcer deteriorated so rapidly, and the DON was unable to specify when certain interventions were implemented. The resident ultimately developed a wound infection and osteomyelitis, resulting in actual harm.