Failure to Prevent Development of Unstageable Pressure Ulcer
Penalty
Summary
A resident was admitted to the facility with intact skin and medical diagnoses of muscle weakness and lymphedema. The resident required staff assistance for bed mobility and transfers and had an intact cognitive status. Upon admission, the skin evaluation showed no abnormalities. However, an open area was first observed on the resident's buttocks nearly a month after admission. Subsequent skin evaluation documented the wound as unstageable, with measurements indicating deterioration. The wound was attributed to the resident not being turned and repositioned as needed, as well as delays in incontinence care. Interviews with facility staff revealed that the wound care nurse was informed of the wound during routine rounds and immediately involved the wound care physician for assessment and intervention. The wound care nurse stated that turning and repositioning are standard interventions for at-risk patients but was unsure how the wound developed in this case. The Director of Nursing confirmed being notified of the wound after its discovery and that interventions were implemented at that time. Review of facility policy showed that the skin and wound guidelines did not address prevention of wound development.