Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
A resident with severe cognitive impairment and multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease, coronary artery disease, and heart failure, was admitted without any existing wounds but was identified as being at risk for pressure ulcers. Despite this risk, the facility failed to implement and document appropriate wound care and monitoring. Physician notes indicated the development of an unstageable pressure ulcer on the resident's right buttocks, but there were no corresponding treatment orders or evidence of wound care in the medical record. Subsequent nursing evaluations documented additional pressure ulcers on the resident's heels, left medial calf, and coccyx, with delayed notification and action from the nursing staff and DON. Further review revealed that orders for necessary interventions, such as the use of prevalon boots and wound care, were not added until several days after the ulcers were identified. The resident's representative reported that the resident was sent to the emergency room for another issue, where concerning pressure ulcers were found, and the resident did not return to the facility. The interim DON confirmed that there was no documentation of wound care or treatment prior to the resident's discharge, indicating a failure to provide timely and appropriate pressure ulcer prevention and treatment.