Failure to Follow Wound Care Orders Resulting in Stage 4 Pressure Injury and Sepsis
Penalty
Summary
Facility staff failed to provide pressure ulcer care and prevent new ulcers from developing for a resident with multiple comorbidities, including heart disease, respiratory failure, COPD, diabetes, and end-stage renal disease. The resident was admitted without pressure ulcers but was identified as being at risk for skin breakdown. Despite care plan interventions such as weekly skin checks and use of a pressure-reducing device, the resident developed a sacral wound during her stay. Physician orders for wound care were not followed on multiple documented occasions, as evidenced by gaps in the treatment administration record. The wound, initially noted as a small opening, progressed in size and severity over several weeks. Documentation and interviews revealed that wound care was either not performed or not documented as performed on several dates, and the wound deteriorated to an unstageable and then stage 4 pressure injury. The resident's family ultimately intervened, resulting in the resident's transfer to the hospital, where she was diagnosed with a stage 4 pressure injury, infection, and severe sepsis. Interviews with facility staff, including the ADON, DON, wound care nurses, and other nursing staff, confirmed that there was a failure to follow physician orders for wound care and to document treatments provided. Staff acknowledged the risks associated with not following wound care protocols and the importance of documentation. The wound care nurse responsible for the resident's care was no longer employed at the facility at the time of the investigation, and staff reported recent in-services on wound care and skin assessments.