Failure to Prevent and Treat Heel Ulcers Resulting in Sepsis and Death
Penalty
Summary
The facility failed to prevent the development of unstageable ulcers, properly identify and assess newly developed ulcers, consistently implement interventions to promote healing, and follow physician orders for wound care for a resident with multiple comorbidities, including Parkinson's disease, diabetes, and peripheral vascular disease. The resident was admitted without heel ulcers, but later developed full-thickness arterial wounds on both heels. Documentation shows that the right heel ulcer was first identified after the resident's daughter noticed blood on the sock, but there was no physician order for treatment of this wound for approximately two weeks. The left heel ulcer was not documented or assessed until it was identified by the wound specialist, and there was no record of when it first developed or how it was initially managed. Throughout the resident's stay, there were significant lapses in wound assessment and documentation. Weekly skin records and progress notes failed to consistently document the status of the heel ulcers, and there were missed assessments on several dates. The care plan did not include specific interventions such as heel offloading or heel protection, despite the resident's high risk for skin breakdown. Orders for heel protectors were not implemented until late in the course of the resident's decline. Additionally, wound care interventions, such as debridement and dressing changes, were inconsistently documented, and there was no evidence that wound cultures were obtained or that antibiotics were started in response to signs of infection, despite care goals indicating the presence of odor and infected tissue. The resident's condition deteriorated, with increasing lethargy, fever, and hypotension, eventually leading to hospitalization for sepsis, gangrene, and necrosis of the bone and surrounding tissue in both heels. Hospital records confirmed the presence of large, necrotic, foul-smelling ulcers with exposed bone and tendon, requiring surgical debridement. The resident was subsequently placed on hospice and died from cardiorespiratory failure due to septic shock. The survey identified Immediate Jeopardy due to the facility's failure to provide appropriate wound care and follow physician orders, resulting in severe harm and death.