Failure to Prevent and Document Facility-Acquired Stage 3 Pressure Ulcer
Penalty
Summary
A resident was admitted to the facility with multiple diagnoses, including cirrhosis of the liver, lymphedema, difficulty walking, and weakness. Upon admission, assessments and documentation indicated that the resident did not have a pressure ulcer (PU) on the left hip, though the resident was identified as being at risk for developing PUs. The resident's baseline and comprehensive care plans noted skin concerns and risk factors, but there was no documentation of a left hip wound at admission. Routine skin assessments were scheduled twice weekly, typically on shower days, and staff were expected to document any skin alterations or breakdowns observed during these assessments. Despite these protocols, the resident developed a facility-acquired Stage 3 pressure ulcer on the left hip, which was first identified during an outpatient wound care physician visit. Prior to this consult, facility records and treatment administration records consistently indicated that the resident's skin was intact, and there was no evidence of a left hip wound. The wound care physician attributed the new ulcer to the resident's wheelchair being too small and recommended specific wound care interventions. However, there was no documented evidence in the facility's records of wound measurements or a detailed assessment of the new ulcer upon the resident's return from the consult, as required by facility policy. Interviews with nursing staff and facility leadership revealed that while skin assessments were performed and documented as intact, there was a lack of follow-up and documentation when the new Stage 3 pressure ulcer was identified. The nurse who received the resident after the wound care consult documented the new recommendations but did not record wound measurements or complete an incident report. The DON was not made aware of the new wound, and there was no investigation or documentation of the wound's development or progression. Facility policies required comprehensive documentation and assessment of new wounds, including measurements and incident reporting, but these steps were not followed in this case.