Failure to Timely Identify and Assess Pressure Ulcers
Penalty
Summary
Facility staff failed to thoroughly assess and monitor the skin condition of a resident who was admitted with multiple pressure ulcers and identified as high risk for developing additional ulcers. Despite physician orders for daily skin sweeps and a care plan that included interventions such as regular repositioning, off-loading devices, and daily wound evaluation, documentation indicated that staff signed off on completing daily skin sweeps without detecting new skin issues. Weekly skin assessments initially reported no new concerns, but a subsequent assessment revealed new skin issues. Ultimately, a wound nurse practitioner identified an unstageable pressure ulcer with slough and necrotic tissue on the resident's right gluteal fold, which had not been previously documented by staff. The resident involved had significant cognitive impairment and required extensive assistance with activities of daily living. The facility's own policy and national guidelines require comprehensive and ongoing skin assessments, particularly for high-risk individuals. However, the new pressure ulcer was not identified until it had progressed to an advanced stage, indicating a failure in timely detection and intervention by staff. The Director of Nursing confirmed that the pressure ulcer was not recognized until it had become unstageable, despite daily documentation indicating that skin sweeps were performed.