Failure to Prevent and Manage Pressure Ulcers Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents, resulting in an Immediate Jeopardy situation. For one resident with severe cognitive impairment and multiple comorbidities, the facility did not conduct comprehensive weekly head-to-toe skin assessments as required by policy. Nursing staff reported that skin assessments were delegated solely to wound care staff, and there was no evidence of regular or thorough assessments by other nurses. Preventive treatments ordered for the resident's heels were not consistently documented as provided, and significant skin breakdown, including multiple unrecognized pressure ulcers, was only identified after the resident was hospitalized for sepsis and other acute conditions. The hospital documented several advanced pressure ulcers that had not been previously identified or treated by the facility, necessitating surgical intervention. Another resident, also with severe cognitive impairment and high risk for skin breakdown, was admitted with an existing stage II pressure ulcer. The care plan required frequent repositioning and weekly skin assessments, but the facility failed to consistently implement these interventions. Turn and repositioning logs showed multiple missed intervals, especially during overnight hours, and weekly skin assessments were not completed as required. Wound documentation was incomplete, lacking essential details such as wound measurements, staging, and progress notes. The resident developed additional wounds, including a deep tissue injury that progressed to necrosis, and experienced a decline in nutritional intake without timely reassessment or intervention. Staff interviews revealed confusion and lack of communication regarding responsibility for physician notification and care plan updates, particularly during the absence of the wound care nurse, who was not replaced during her leave. Facility leadership and clinical staff interviews confirmed systemic failures in communication, documentation, and oversight of wound care and prevention practices. Wounds were not routinely discussed in clinical meetings, and there was a lack of leadership in ensuring that assessments, interventions, and documentation were completed according to policy. The newly appointed wound care physician and nurse identified widespread deficiencies in skin care practices, including lack of preventive measures, inadequate staff education, and insufficient monitoring. These failures resulted in multiple residents developing or experiencing worsening pressure ulcers that were not promptly identified or treated.