Failure to Prevent and Manage Pressure Injuries Resulting in Harm and Death
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and manage pressure injuries for three residents, resulting in significant harm, including death. One resident, admitted with high risk factors such as impaired mobility, incontinence, and a high Braden score, did not have individualized interventions like turning and repositioning or an air mattress added to their care plan, despite repeated assessments and recommendations from an APRN. Documentation of skin assessments was incomplete, and there was no evidence of timely wound evaluation or care plan updates after the development of sacral redness and subsequent pressure injury. The resident's condition deteriorated to an unstageable, necrotic pressure injury, leading to hospitalization for osteomyelitis and sepsis, and ultimately death. The facility's policies for skin and wound assessment, care planning, and communication among staff were not followed, and the DON acknowledged lack of staff support and failure to update care plans or review clinical notes. Another resident, identified as high risk for skin breakdown, developed an open wound on the left shoulder. Although the APRN documented the wound and provided treatment orders, these were not entered into the medical record, and the care plan was not updated to reflect the new wound. There was no evidence of monitoring or treatment of the wound, and the area was not included in skin assessments or the facility's wound tracker. The DON was unaware of the wound, and the APRN did not communicate new findings during wound rounds. A third resident with cerebral palsy and a significant hand contracture developed a deep tissue injury (DTI) on the right index finger. The care plan did not include interventions to prevent pressure injury to the contracted hand, and recommendations for protective measures, such as a finger separator, were not implemented. The DON stated that the absence of a formal contracture diagnosis was the reason for not including specific preventive interventions in the care plan, despite the resident's limited range of motion and observed contracture.