Failure to Provide Timely Pressure Ulcer Prevention and Treatment
Penalty
Summary
A resident with multiple complex medical diagnoses, including acute respiratory failure, chronic kidney disease, diabetes, morbid obesity, and limited mobility, was admitted to the facility and identified as being at moderate risk for pressure injury (PI) development. Initial skin and Braden assessments documented the resident's risk, but the Minimum Data Set (MDS) assessment for PI risk had not yet been completed. Despite the resident's risk status, the facility failed to implement and update necessary interventions after shearing was first observed on the resident's coccyx. On several occasions, staff did not follow physician orders for wound care and pressure injury prevention. For example, a prescribed foam dressing was not consistently applied as ordered, and a nurse removed the dressing to allow the wound to air dry without consulting the provider or updating treatment orders. Additionally, the facility did not promptly apply an air mattress or alternative interventions when equipment was delivered, and there was a lack of timely and accurate documentation regarding the resident's skin condition and Braden scores. The care plan and Master Communication Sheet (MAS) were not updated to reflect new interventions after the initial identification of skin breakdown. Interviews with staff revealed confusion and lack of clarity regarding the resident's wound care plan and the implementation of preventive measures. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that interventions such as repositioning and wound care should have been initiated and documented following the first signs of shearing. The failure to update care plans, follow treatment orders, and implement timely interventions contributed to the development and progression of a stage 2 pressure injury in the resident.