Failure to Maintain Dressing on Stage 4 Pressure Injury
Penalty
Summary
A resident with a history of spina bifida, urinary tract infections, wheelchair dependence, malnutrition, and a stage 4 pressure injury to the left buttock was admitted to the facility with physician orders for daily application of calcium alginate dressing to the wound. On the day of the survey, the resident's dressing came off during a shower, and the Certified Nursing Assistant (CNA) did not replace it, instead waiting for the wound care doctor to arrive. The resident was left in bed without a dressing on the pressure injury for several hours, despite the wound care doctor being present in the building but not yet having visited the resident. The resident reported that no staff had replaced the dressing and that he remained in bed waiting for the wound doctor, although he preferred to be in his wheelchair. Record review showed that the dressing was not documented as completed on two separate days, including the day of the observation. The wound evaluation confirmed the presence of a stage 4 pressure injury with specific measurements and a treatment plan requiring daily and as-needed dressing changes if the dressing became saturated, soiled, or dislodged. Facility policy required the use of protective dressings for at-risk individuals and replacement of dressings if they came off. The Director of Nursing confirmed that dressings should be replaced if they come off, indicating that the facility failed to ensure appropriate pressure ulcer care by not maintaining a dressing on the resident's wound as ordered.