Failure to Assess and Treat Pressure Ulcers Results in Serious Harm
Penalty
Summary
A facility failed to complete a comprehensive skin assessment and provide necessary treatment for a resident who returned from a hospital admission with multiple pressure ulcers. Upon readmission, the hospital discharge summary documented pressure ulcers on the coccyx, left heel, right heel, and lateral right foot, with instructions for wound cleansing and dressing changes. Despite these documented wounds and clear orders for wound care, the facility did not assess, monitor, or treat these pressure ulcers for approximately six weeks. Nursing documentation and care plans failed to reflect the presence or treatment of these wounds, and the Treatment Administration Record (TAR) did not include the required wound care interventions. The resident, who was dependent on staff for all activities of daily living and had significant comorbidities including chronic heart failure, opioid dependence, and chronic pain, experienced severe pain that made repositioning and skin assessments difficult. Staff interviews revealed confusion and lack of communication regarding responsibility for wound care, with some believing hospice was responsible, while hospice staff indicated the facility was to provide wound care per the plan of care. During this period, the resident was observed with untreated wounds, dirty dressings, and ongoing severe pain, with no evidence of regular repositioning or adequate pain management to facilitate wound care or assessment. Documentation and interviews further showed that weekly skin inspections and wound assessments were either not performed or not documented, and that staff did not notify providers or update care plans to reflect the resident's condition. The lack of assessment, monitoring, and treatment resulted in the resident's wounds going untreated for an extended period, with staff only identifying and addressing the wounds after surveyor intervention. The facility's failure to follow its own policies and professional standards of practice led to serious harm for the resident.