Failure to Prevent and Manage Pressure Ulcer Resulting in Harm
Penalty
Summary
A resident with a history of nontraumatic intracerebral hemorrhage, aphasia, dysphagia, and total dependence for activities of daily living was admitted to the facility without any skin impairment. Upon admission, assessments identified the resident as high risk for pressure ulcers due to immobility, incontinence, and comorbidities. The care plan included interventions such as keeping the resident clean and dry, performing peri care after each incontinent episode, and using emollients and barrier creams as recommended by the wound nurse practitioner. However, the clinical record lacked documentation that these preventive measures were implemented, including the use of emollients, barrier creams, regular turning and repositioning, and off-loading. Within two weeks of admission, the resident developed a stage II pressure ulcer on the coccyx, which rapidly progressed to an unstageable wound requiring surgical debridement and hospitalization. Documentation was missing regarding the identification of the wound, notification of the physician or family, and initiation of appropriate nursing interventions when the wound was first observed. Preventive skin care orders were not documented in the Medication Administration Records, and there was no evidence that a personalized skin care plan was developed or implemented prior to the development of the pressure ulcer. Interviews with staff and review of facility policy revealed that the resident was dependent on staff for all care, including incontinence management and repositioning, but there was no documentation to confirm these interventions were consistently provided. The facility's policy required prompt identification of at-risk residents and immediate implementation of specific interventions, but the record did not show that these steps were taken before the pressure ulcer developed. The lack of preventive care and timely intervention resulted in actual harm to the resident, who required hospitalization and advanced wound care.