Failure to Prevent and Identify Pressure Ulcer Resulting in Resident Harm
Penalty
Summary
A resident was admitted to the facility following a critical illness, with a history of recent surgeries and existing wounds to the abdomen and heels, but no wounds to the coccyx. The resident was identified as being at high risk for pressure ulcers, as indicated by multiple Braden scale assessments, and required extensive assistance with activities of daily living due to immobility, incontinence, and neurocognitive disorder. The care plan included several interventions for skin integrity and pressure ulcer prevention, such as use of a low air loss mattress, heel protection devices, and regular skin checks. However, documentation revealed that nurse aides did not consistently record turning and repositioning, and there were multiple shifts where no evidence of turning was documented. Additionally, there were no physician orders or care plan interventions specifically addressing the coccyx area, and no wound to the coccyx was documented during the resident's stay or at discharge. Upon transfer to another facility, an immediate skin assessment revealed a deep, foul-smelling wound to the coccyx, covered with a dressing dated the day of discharge. The receiving LPN described the wound as possibly exposing bone, with significant odor and necrotic tissue, and noted that the wound was not reported by the sending facility. The wound was subsequently assessed as an unstageable, necrotic pressure ulcer with signs of infection and tunneling, requiring debridement and intravenous antibiotics. The receiving facility's staff and medical records confirmed that the wound was present and untreated upon arrival, and that no prior notification or documentation of the coccyx wound had been provided by the sending facility. Interviews with the facility's DON, wound nurse, and administrator revealed a lack of awareness regarding the coccyx wound, and they could not explain how a dressing came to be applied to the area. The wound nurse and LPN responsible for wound care denied knowledge of any coccyx wound during the resident's stay, and the medical director stated he relied on staff documentation for skin assessments. The absence of documentation, lack of targeted interventions for the coccyx, and failure to identify or treat the wound resulted in the resident sustaining actual harm, as evidenced by the development of a severe, infected pressure ulcer requiring hospitalization and advanced wound care.