Failure to Implement Pressure Ulcer Interventions Resulting in Wound Deterioration
Penalty
Summary
The facility failed to consistently implement planned interventions and provide necessary treatment and services to prevent the worsening of a pressure ulcer for a resident with significant cognitive impairment and multiple care needs. The resident was admitted with a Stage 2 pressure ulcer and was identified as being at moderate risk for pressure injuries, requiring total staff assistance for activities of daily living, including turning and repositioning. The care plan included specific interventions such as application of a protective barrier cream after incontinence episodes, regular turning and repositioning, weekly skin inspections, wound evaluations, and use of pressure-reducing devices. Despite these planned interventions and recommendations from the wound care consultant, documentation revealed that the recommended barrier cream was not ordered or applied as directed, and there was no consistent evidence that staff turned and repositioned the resident according to the care plan. Additionally, wound measurements and thorough evaluations were not consistently documented, making it difficult to assess the wound's progression or the effectiveness of interventions. The resident's pressure ulcer worsened from a Stage 2 to an unstageable wound, with a significant increase in size and the presence of slough, indicating a decline in skin integrity. Interviews with facility leadership confirmed the lack of evidence for implementation of the wound care consultant's recommendations, absence of a consistent turning and repositioning schedule, and insufficient evaluation of the wound's status. There was also no documentation of updated or intensified interventions in response to the worsening wound, contrary to facility policy and best practice guidelines for pressure ulcer management.