Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. One resident, who wore a Life Vest (a wearable cardioverter defibrillator), reported that the vest was too tight and caused a painful wound on his torso. Despite the resident's complaints and visible skin impairment, there was no documentation of a skin assessment or treatment for the wound upon admission, and the care plan did not address the medical device-related wound or include interventions for monitoring skin under the vest. Weekly skin checks were ordered, but the vest was only removed for showers, limiting the ability to assess and protect the skin. The wound was eventually identified as a full-thickness pressure injury with slough and black, scab-like areas, but documentation and intervention were delayed, and there was no evidence of timely communication with the vest provider for a better fit. Another resident, who was quadriplegic and required total assistance for care, developed multiple pressure ulcers, some of which were acquired in the facility. The clinical record showed a lack of timely and accurate documentation of skin impairments, with wounds first identified at advanced stages (Unstageable or Stage 3) by a wound care consultant. There were significant gaps in weekly skin observations, and new wounds were not documented by facility staff prior to consultant identification. The care plan included general monitoring instructions, but there was no evidence that staff consistently monitored, documented, or reported changes in skin condition as required. Interviews with the DON and ADON revealed a lack of clear oversight and accountability for wound care, with inconsistent skin checks and delayed identification of wounds. The facility's own policy required daily skin inspections and immediate reporting of any signs of breakdown, but these procedures were not followed. The deficiencies resulted in the development and worsening of pressure ulcers for both residents, with inadequate documentation, assessment, and intervention throughout their stays.