Failure to Assess, Monitor, and Intervene for Pressure Ulcer Risk and Treatment
Penalty
Summary
A deficiency was identified when the facility failed to properly assess, monitor, and intervene for a resident with a history of skin breakdown and at high risk for pressure ulcers. Upon admission, the resident was documented as having moisture associated skin damage to the right gluteus, but there was no documentation of a deep tissue injury or other wounds. Despite this, there was a lack of accurate and timely documentation regarding the resident's skin condition, and the baseline care plan did not address any skin issues or concerns. The facility also failed to initiate appropriate treatment orders for the skin damage present on admission, and there was no evidence of wound care interventions until a pressure ulcer was later identified. Throughout the resident's stay, multiple nursing notes, skin checks, and care plan reviews continued to document the presence of moisture associated skin damage, but did not identify or address the development of a pressure ulcer. The Braden scale assessments initially indicated a low risk for pressure ulcers, and there was inconsistency in the documentation of the resident's skin status. The care plan eventually noted the resident was at risk for skin breakdown due to incontinence, but did not specifically address the presence or treatment of a pressure ulcer. Weekly wound tracking and physician notes later documented the progression of a sacral wound from suspected deep tissue injury to a stage IV pressure ulcer, with significant necrotic tissue and exudate, and additional wounds on the right heel and left foot. Communication failures were evident, as changes in the resident's skin condition were not consistently reported to the care team or reflected in the care plan. There was a delay in obtaining and following physician orders for wound care, and discrepancies existed between the frequency of ordered dressing changes and what was scheduled in the electronic medical record. The lack of timely and coordinated interventions contributed to the deterioration of the resident's skin condition, ultimately resulting in severe infection, sepsis, and death due to complications from an infected sacral decubitus ulcer.