Failure to Prevent and Identify Pressure Ulcer Resulting in Harm
Penalty
Summary
A resident was admitted to the facility following a critical illness, with multiple surgical wounds and deep tissue injuries to both heels, but no pressure ulcer to the coccyx. The resident was identified as being at high risk for pressure ulcers, as evidenced by repeated low Braden scale scores and a care plan that included multiple interventions for skin integrity and pressure ulcer prevention. The care plan specified the need for frequent skin assessments, use of pressure-relieving devices, and regular turning and repositioning due to the resident's immobility, incontinence, and history of cerebrovascular accident with paraplegia. Despite these identified risks and interventions, documentation revealed that staff did not consistently record turning and repositioning for all shifts, with several days lacking documentation for all three shifts. There were no physician orders or documented treatments specifically for the coccyx area, and weekly skin and wound assessments provided by the facility did not note any coccyx wound prior to discharge. Upon discharge, there was no documented skin or wound evaluation for the coccyx, and the discharge report to the receiving facility did not mention any new skin issues. Shortly after transfer, the receiving facility performed a body audit and discovered a deep, foul-smelling, unstageable pressure ulcer with necrotic tissue on the coccyx, covered by a dressing dated the day of discharge. The wound was subsequently assessed as infected and requiring debridement, with the resident being hospitalized for treatment of a Stage III decubitus ulcer with osteomyelitis. Staff at the original facility, including the wound nurse and DON, denied knowledge of the coccyx wound and could not explain the presence of the dressing. The lack of documentation, assessment, and intervention for the coccyx area led to actual harm to the resident.