Failure to Assess and Intervene for Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and implement timely interventions for a resident with skin integrity concerns, resulting in the progression of a pressure injury and delayed wound healing. Upon the resident's return from the hospital, where a deep tissue injury to the left heel had been documented, there was no documentation of a skin assessment or any skin concerns. Body audits conducted in the days following readmission did not mention the left heel, and the pressure injury was not identified until eight days later, by which time it had progressed to an unstageable wound. The charge nurse confirmed that a body audit was not performed on readmission, and the DON acknowledged that no interventions were implemented to address the known skin concern at that time. Additionally, when redness was later observed on the resident's buttocks, no treatment was initiated, and the nurse who noted the redness admitted to not documenting or initiating wound care orders due to being busy. This lack of assessment and follow-through with treatment allowed both the left heel and sacral wounds to progress. The resident involved had a history of dementia with anxiety and was severely cognitively impaired at the time of the deficiency, further emphasizing the need for diligent assessment and intervention.