Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
A resident with a history of cardiac arrest resulting in anoxic brain damage, congestive heart failure, hypernatremia, acute respiratory failure with hypoxia, acute kidney injury, and PEG tube status was admitted to the facility. Upon admission, a skin assessment noted redness and superficial breakdown on the sacrum, with orders for cleansing and application of Triad cream for wound prevention. Five days later, a subsequent skin assessment documented shearing to the sacrum and indicated that a pillow was being used to offload pressure, with continued monitoring and prevention as ordered. However, a wound care note shortly thereafter identified a stage III pressure injury on the sacrum, measuring 6cm x 11cm x 0.2cm, with serosanguineous drainage, and treatment orders were updated to include Triad cream and a bordered foam dressing. Interview with the resident's family member revealed concerns that the resident was not being turned and repositioned as needed and was not receiving adequate hydration. The family member reported having to seek out nursing staff to turn the resident during visits. The DON acknowledged the resident required total care and had significant edema, and also noted discrepancies in wound documentation between nursing staff and wound care personnel. The findings indicate a failure to provide consistent and adequate care and services to prevent the development or worsening of pressure ulcers for this resident.