Failure to Prevent and Timely Treat Pressure Ulcer Resulting in Stage IV Wound
Penalty
Summary
A resident with significant medical conditions, including cerebral infarction, dysphasia, adjustment disorder, and moderate protein-calorie malnutrition, was admitted to the facility and identified as being at moderate risk for pressure ulcers. The resident was severely cognitively impaired, required extensive assistance with activities of daily living, and was bedfast. Initial care plans and orders included regular skin assessments, use of barrier creams, and pressure-relieving mattresses. However, documentation revealed gaps in the implementation of these interventions, including a period from mid-November to early December when no skin treatments were administered despite ongoing skin issues such as excoriation and discoloration. Throughout the resident's stay, weekly skin sweeps consistently noted excoriation and skin breakdown on the buttocks, but there was a lack of timely and appropriate escalation in wound care. Orders for skin barrier ointment were not transferred to the treatment administration record, and there was no evidence that these treatments were provided. When wound care was eventually initiated, the wound had progressed to a full-thickness injury. Recommendations for further interventions, such as wound imaging and specific wound treatments, were either delayed or not implemented at all. For example, an order for an x-ray to rule out osteomyelitis was not completed, and recommended treatments like Dakins solution were not ordered or administered. The resident's condition deteriorated, resulting in the development of a Stage IV pressure ulcer with associated osteomyelitis, necessitating an extensive hospital stay. Interviews with facility staff, including the wound nurse, nurse practitioner, and DON, revealed a lack of awareness regarding the resident's wound progression and lapses in following through with prescribed treatments and assessments. The facility's own policy required systematic skin assessments and timely interventions for residents at risk, but these were not consistently followed, directly contributing to the resident's severe wound development.