Failure to Timely Identify and Treat Pressure Ulcers Resulting in Stage IV Wounds
Penalty
Summary
A deficiency occurred when the facility failed to implement timely treatment for pressure ulcers after they were identified in a resident who was admitted without pressure ulcers but was at high risk for their development. The resident, who had chronic respiratory failure, encephalopathy, epilepsy, and was in a persistent vegetative state, was dependent on staff for all activities of daily living and received tube feeding. Despite care plans and physician orders for regular skin checks and preventative interventions, the resident developed pressure ulcers on both antecubital spaces (inner elbows), which were not documented or treated promptly. Certified Nursing Assistant (CNA) identified open areas on the resident's inner elbows during a shower and reported them to the nurse on duty. However, there was no documentation of these open areas in the medical record for several days, and no treatment was initiated until nearly a week later, by which time the wounds had progressed to stage IV pressure ulcers with exposed tendon. Weekly skin checks conducted prior to this did not note any open areas, and the facility's policy required immediate assessment and documentation by licensed nurses upon identification of new pressure injuries. Interviews with staff revealed a lack of timely communication and follow-up after the CNA's report, with the wound nurse unable to recall when she was notified. The Director of Nursing acknowledged the resident's compromised condition but confirmed that timely treatment was not obtained. The facility's failure to act promptly on the initial identification of skin breakdown led to the development of severe pressure ulcers, as confirmed by subsequent wound assessments and observations.