Failure to Prevent and Treat Pressure Ulcers and Timely Manage Wound Infections
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents, as evidenced by direct observations, interviews, and record reviews. One resident with Alzheimer's disease and muscle weakness was observed multiple times without the prescribed pressure-relieving boot on her left foot, despite care plan interventions requiring its use at all times. Her left heel was later found to be darkened and sore, indicating the development of a pressure injury. Staff only applied the pressure-relieving boot after the injury was identified, and the wound nurse confirmed that the boot and skin prep were necessary to prevent breakdown. Another resident, who was severely contracted, cognitively impaired, and at high risk for pressure injuries, experienced multiple failures in pressure ulcer prevention and treatment. This resident's low air loss mattress malfunctioned, causing him to lie directly on the metal bed frame without adequate pressure relief. Despite physician orders for pressure-relieving devices and frequent repositioning, the resident developed new deep tissue injuries that progressed to Stage IV pressure ulcers, exposing tendon and hardware. Documentation revealed lapses in following wound care orders, inconsistent application of prescribed treatments, and incomplete or missing documentation of wound care and medication administration. The facility also failed to obtain and process wound cultures in a timely manner, resulting in delays in identifying and treating wound infections. There were significant delays in starting IV antibiotics due to issues with venous access and lack of timely PICC line placement. Medication administration records showed missed doses of prescribed antibiotics, and there was no documentation explaining these omissions. Additionally, maintenance and nursing staff were unable to provide accurate records of when pressure-relieving equipment was malfunctioning or replaced, further contributing to the inadequate care and worsening of pressure ulcers.