Failure to Timely Identify and Manage Pressure Ulcer Resulting in Harm
Penalty
Summary
Facility staff failed to protect a resident from neglect by not providing timely identification and management of a pressure wound. The resident, who was non-verbal and had multiple risk factors including poor mobility, dementia, malnutrition, and incontinence, developed a sacral/coccyx pressure ulcer that was not identified until it was already at an advanced stage with over 70% slough. After initial identification, staff did not obtain a physician order for wound care, nor did they provide any documented treatment for several days. The wound was not assessed or treated again until a wound specialist evaluated the resident five days later, at which point the wound required sharp debridement. Following the wound specialist's assessment, facility staff failed to promptly implement the recommended treatment orders, with further delays in changing wound care orders after subsequent specialist visits. There were multiple documented lapses in providing wound care as ordered, including missed treatments on several days and failure to apply specific interventions such as zinc to the peri-wound area. Additionally, staff did not consistently document or perform required repositioning every two hours, despite active physician orders, and there was no evidence of documentation to support that these interventions were being carried out. The facility also neglected to obtain a timely x-ray to rule out osteomyelitis, despite repeated recommendations from the wound specialist over several weeks. The x-ray order was not transcribed or initiated until more than two weeks after the initial recommendation, and there was confusion and lack of documentation regarding the delay. Interviews with staff and the DON revealed gaps in communication, documentation, and follow-through on wound care protocols, as well as incomplete or missing audits and education records related to wound management. The facility's QAPI action plan was found to be incomplete and lacking evidence of implementation prior to the survey.