Failure to Timely Identify Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to identify a pressure ulcer in one resident who was at high risk for skin breakdown due to cognitive deficits, decreased sensation, diabetes mellitus, neuropathy, incontinence, and edema. During a wound dressing change, the wound nurse observed an unstageable pressure ulcer on the resident's sacrum, characterized by slough and eschar, absence of granulation tissue, and a red peri-wound area with foul-smelling drainage. The wound was determined to be facility-acquired, and the wound nurse acknowledged that the pressure sore should have been detected before reaching an unstageable stage. Review of the resident's care plan indicated interventions for monitoring skin integrity and prompt physician notification of skin breakdown, but the new pressure ulcer was not identified until it had progressed significantly. Facility policy requires regular observation, measurement, and documentation of pressure areas, as well as immediate reporting of skin conditions by certified nursing assistants. Despite these protocols, the pressure ulcer was not identified in a timely manner, resulting in a facility-acquired, unstageable wound.