Failure to Accurately Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to accurately and timely identify and provide treatment for pressure ulcers, affecting two residents out of three reviewed for wound care. For one resident with multiple medical diagnoses including aphasia, anemia, and an unstageable sacral pressure ulcer, the admission skin assessment did not identify any skin impairments. However, within weeks, staff documented new open areas and wounds on the buttocks, but failed to provide a comprehensive wound assessment, including details such as wound depth, bed, drainage, odor, and surrounding skin condition. Dressings were applied without physician orders, and there was a delay in obtaining appropriate treatment orders. The care plan was not updated promptly to reflect the new wounds, and facility policy requiring full wound assessment and timely physician notification was not followed. Another resident, admitted with a history of stage two pressure ulcers and multiple comorbidities, was documented by hospital records as having red, open areas on the buttocks. The facility's admission assessment described these as lacerations/abrasions, without adequate description of the wound bed or surrounding skin, and failed to document the presence of moisture associated skin damage (MASD). Throughout the resident's stay, wound assessments lacked detail, and there was inconsistency in wound identification, with staff and providers disagreeing on whether the wounds were MASD or stage two pressure ulcers. Dressings were applied without physician orders, and wound documentation did not consistently include required elements such as depth and wound bed description. Photographs of the wounds were not taken by the facility, and event reporting was incomplete. Interviews with nursing staff, the wound nurse, DON, and physician revealed gaps in knowledge regarding wound identification and assessment, as well as inconsistent documentation and communication. Facility policies required comprehensive wound documentation, timely notification of changes in condition, and appropriate use of wound care products, but these were not consistently followed. The deficiencies were identified through observation, record review, and staff interviews, and affected residents with significant risk factors for skin breakdown.