Failure to Identify and Treat Pressure Ulcers Resulting in Worsening Wounds
Penalty
Summary
The facility failed to correctly identify, assess, and treat pressure ulcers, resulting in worsening and non-healing wounds for three residents. For one resident, there was a lack of proper documentation and assessment for a wound on the left palm, despite clear evidence of an open wound caused by hand contractures and fingernails. The Clinical Care Coordinator was unaware of the wound's occurrence or the implementation of hand carrot orders, and there was no photographic evidence or wound assessment documented. Additionally, the physician was not notified, and no change in condition form was completed for this wound. The same resident developed a sacral wound that was initially misclassified as a Kennedy terminal ulcer (KTU) rather than a pressure injury. The wound's progression, including gradual changes in size, tissue composition, and periods of improvement and regression over 16 weeks, was inconsistent with the rapid and terminal nature of KTUs. Despite the wound's non-healing status, the treatment order remained unchanged for an extended period. The resident also developed a right trochanter wound over an implanted pain pump, which similarly persisted and worsened over several weeks, eventually exposing and dislodging the device. Both wounds were managed with treatments such as AquaCell AG, but there was a lack of timely reassessment and modification of care plans in response to the wounds' progression. Interviews with staff revealed inconsistent understanding and application of wound assessment protocols. Nurses and physicians relied heavily on photographs and electronic documentation rather than in-person assessments, and wounds were not always staged or reassessed appropriately. Weekly skin assessments failed to reflect the resident's declining skin integrity, and there was a lack of communication and documentation regarding changes in condition. The misclassification of pressure injuries as KTUs led to inadequate care planning and treatment, contributing to the worsening and non-healing of the residents' wounds.