Failure to Prevent and Manage Stage 4 Pressure Ulcers
Penalty
Summary
A deficiency was identified when a resident developed and experienced progression of two stage 4 pressure ulcers, one on the left ischium and another on the scrotum, despite being under the care of the facility. The scrotal pressure ulcer was attributed to improper placement of wound vac tubing, which was observed pressing against the resident’s skin. Documentation and staff interviews confirmed that the wound vac was not applied correctly, and the tubing was not properly bridged, resulting in a deep tissue injury that progressed to a stage 4 pressure ulcer. The resident experienced severe pain during dressing changes and required wound debridement and antibiotics due to infection. The resident had a history of significant medical conditions, including hypertension, diabetes mellitus, depression, spastic hemiplegia, and a pre-existing stage 4 pressure ulcer. Despite these risk factors and a care plan that included interventions to prevent skin breakdown and ensure proper use of medical devices, the facility failed to prevent the development of a new pressure ulcer and the worsening of existing wounds. Wound assessments over several months documented that the wounds were not healing and, in some cases, were deteriorating, with exposed muscle and bone, tunneling, and repeated need for debridement. Further review revealed that the resident’s pressure-relieving equipment, such as a ROHO cushion, was found deflated and had not been properly maintained or reassessed by therapy staff after the development of the pressure injury. Occupational therapy notes did not include a reassessment of the wheelchair or cushion system, and wound care documentation indicated improper dressing techniques, including the use of creams that may have contributed to maceration. Staff education and performance issues related to wound vac application were also noted, but the deficiency centers on the failure to prevent and properly manage pressure ulcers as required by facility policy and the resident’s care plan.