Failure to Accurately Assess and Stage Pressure Injuries
Penalty
Summary
The facility failed to accurately assess and stage a resident's skin condition for pressure injuries. Upon admission, the resident, who had a history of Type 2 Diabetes Mellitus and was cognitively intact, was noted to have excoriation on the sacral coccyx area. Physician orders directed specific wound care, including cleansing, application of zinc oxide paste, and covering with a foam dressing. During wound care observation, the resident was found to have a dark red line on the coccyx, redness in the gluteal folds, skin breakdown, and peeling, which appeared consistent with partial thickness skin loss. However, the treatment nurse performing the care did not acknowledge the presence of skin breakdown or a potential pressure injury, stating that only wounds with drainage were considered skin breakdown or pressure injuries. A review of the resident's admission wound photograph by another treatment nurse indicated the wound resembled a stage 2 pressure injury upon admission. The Director of Nursing declined to answer specific questions regarding wound staging, although it was stated that all wound nurses were wound care certified. Facility policy required accurate staging of pressure injuries according to standardized guidelines, but the observed and documented actions did not align with these requirements, resulting in a failure to properly assess and stage the resident's pressure injury.