Failure to Consistently Assess and Treat Pressure Ulcers in High-Risk Residents
Penalty
Summary
The facility failed to perform consistent weekly skin assessments for residents at high risk for skin breakdown, resulting in delayed identification of pressure ulcers and inadequate documentation. Multiple residents with significant risk factors, such as immobility, cognitive impairment, and existing wounds, did not receive the required weekly skin assessments as outlined in the facility's own policy. For example, one resident with a history of Stage IV sacral pressure ulcer and multiple comorbidities did not have weekly skin assessments documented for several months, and new or recurrent wounds were only identified during a facility-wide skin sweep prompted by concerns about another resident. Other residents at high risk, including those with severe cognitive impairment, paraplegia, and malnutrition, also had significant gaps in their skin assessment documentation, with some going weeks or months without any recorded assessment. In addition to the lack of timely skin assessments, the facility failed to perform wound treatments as ordered by physicians or recommended by the wound care nurse practitioner for several residents. Medication Administration Records (MARs) revealed missed wound care treatments on multiple occasions, and in some cases, treatments were not initiated until days after wounds were identified. For instance, one resident with multiple Stage III and IV pressure ulcers had several missed wound care treatments, and another resident with an unstageable pressure ulcer to the left heel did not receive a physician's order or treatment until two days after the wound was first identified. There were also instances where wound care orders were not restarted after a resident returned from the hospital, resulting in a lack of wound care for over a month. Interviews with staff and review of facility records indicated systemic issues with the implementation and oversight of the skin integrity and wound care program. Staff responsible for weekly skin assessments were not consistently performing them, and there was confusion or lack of accountability regarding who was responsible for monitoring the program. High turnover among treatment nurses contributed to inconsistent documentation and missed treatments. The facility's own leadership acknowledged gaps in the completion of Braden Scale assessments and weekly skin audits, as well as difficulties in maintaining adequate staffing for wound care. These failures led to the delayed identification and treatment of pressure ulcers in multiple high-risk residents.