Failure to Assess and Treat Blister Led to Stage 4 Pressure Injury
Penalty
Summary
The facility failed to properly assess and treat a blister on the right elbow of a resident who was re-admitted with a history of chronic wounds and high risk for pressure injuries, as indicated by a Braden Scale score of 12. Upon re-admission, the resident's right elbow was wrapped with a bandage, and a blister the size of a ping-pong ball was present, but this was not documented, assessed, or reported to the physician. No treatment order was obtained for the blister at that time, and the presence of the bandage was not investigated further by the admitting nurse. Subsequent interviews and record reviews revealed that the licensed nurses did not perform or document a head-to-toe skin assessment upon re-admission, as required by facility policy. The wound was not unwrapped or measured, and the physician was not notified. The lack of assessment and documentation meant that no care plan or treatment was initiated for the blister, despite the resident's high risk for skin breakdown and pressure injuries. As a result of these failures, the blister on the resident's right elbow worsened and progressed to a Stage 4 pressure injury, with full-thickness skin loss and exposed bone. Staff interviews confirmed that the expected protocol was not followed, and the facility's own policies required immediate assessment, documentation, and intervention for any skin issues identified upon admission or re-admission.