Failure to Prevent and Manage Stage 3 Pressure Ulcers
Penalty
Summary
Facility staff failed to identify and appropriately manage pressure ulcers for two residents, resulting in the development and progression of Stage 3 pressure ulcers. One resident, with a history of a right above-the-knee amputation, atherosclerosis, diabetes, and chronic kidney disease, was admitted and later readmitted to the facility. Initial skin assessments identified only a Stage 1 pressure ulcer and a surgical site, but a subsequent assessment revealed a new Stage 3 pressure ulcer on the right buttock. There was no evidence of a timely nutrition assessment or additional nutritional support after the Stage 3 ulcer was identified, and weekly wound measurements and skin observations were not consistently documented as required. Another resident, diagnosed with quadriplegia, was assessed as being at risk for pressure ulcers according to the Braden Scale. Despite care plans and physician orders for pressure-relieving interventions, the resident developed a Stage 3 pressure ulcer on the right ischium, which was not present on admission. Skin assessments prior to the identification of the ulcer did not document any issues in that area. Interviews revealed that the resident was not consistently turned or repositioned, and staff were not always aware of the presence or severity of the pressure ulcer, leading to delays in implementing appropriate interventions such as specialized support surfaces and nutritional support. Observations and interviews with staff and residents indicated that there were lapses in communication, documentation, and implementation of pressure ulcer prevention and management protocols. Staff were sometimes unaware of the severity of wounds, and recommended interventions were not always put in place in a timely manner. These failures resulted in harm to the residents, as evidenced by the progression of pressure ulcers to advanced stages.