Failure to Prevent and Treat Pressure Ulcers Resulting in Harm and Immediate Jeopardy
Penalty
Summary
Multiple residents experienced significant lapses in pressure ulcer prevention and treatment, resulting in the development and worsening of pressure injuries. Residents with existing wounds or at high risk for pressure ulcers did not receive timely or appropriate wound care interventions as ordered by wound care consultants and medical providers. In several cases, wound care orders were not implemented for days or weeks after being written, and there was a lack of documentation of wound assessments, pain evaluations, and care plan updates. For example, one resident was admitted with multiple pressure ulcers and wounds, but wound treatments were not documented as completed until several days after admission, and subsequent wound care recommendations were repeatedly not implemented in a timely manner. Another resident developed a new deep tissue injury and experienced delays in both wound care and recommended diagnostic workups for possible infection, with the wound care consultant unaware that her recommendations were not being followed due to lack of access to the electronic health record. Other residents at risk for pressure ulcers did not receive regular skin assessments or preventive interventions such as offloading heels, despite care plans indicating their risk. In one case, a resident with a history of heel redness did not have weekly skin assessments or heel offloading interventions in place until after deep tissue injuries were discovered during a facility-wide skin sweep. Another resident developed a stage 1 pressure ulcer and later a suspected deep tissue injury, but did not receive a full wound assessment or pain evaluation until days after the ulcer was identified, and offloading interventions were delayed. A resident admitted for rehabilitation with a pressure ulcer on the coccyx experienced worsening of the wound without additional assessment or documentation, even as the wound increased in size and a new heel ulcer developed. Across these cases, the facility failed to follow its own policies for pressure injury prevention and management, including prompt evaluation, care plan development, and communication among staff and providers. The lack of coordination and documentation led to missed or delayed treatments, unaddressed wound deterioration, and, in one case, a resident requiring hospitalization for osteomyelitis and sepsis related to a pressure ulcer.