Failure to Prevent and Timely Identify Pressure Ulcers and Deep Tissue Injuries
Penalty
Summary
A resident with multiple comorbidities, including hypertension, diabetes mellitus type 2, schizophrenia, dementia, and a history of cerebrovascular accident with left-sided weakness, was admitted to the facility and assessed as being at high to moderate risk for pressure ulcers according to repeated Braden Scale assessments. The resident was dependent on staff for most activities of daily living, including mobility, hygiene, and toileting, and was always incontinent of urine and bowel. Despite care plans and physician orders that included daily body checks, use of pressure-relieving devices, regular skin evaluations, and application of barrier creams, documentation shows that the resident developed multiple wounds, including a Stage 3 pressure ulcer on the left buttock, suspected deep tissue injuries (DTIs) on the right heel and left iliac crest, a diabetic ulcer on the left medial lower leg, and moisture-associated skin damage (MASD) to the buttocks. The facility's records indicate that, prior to the discovery of these wounds, routine skin checks and shower sheets repeatedly documented no new skin issues, bruises, or open areas. However, on a later date, staff identified multiple wounds during a skin assessment, including a Stage 3 pressure ulcer and DTIs, which were not present on admission. Orders for interventions such as foam boots for offloading were not transcribed until after the wounds were identified, and there were inconsistencies in the documentation of wound care administration. Additionally, despite a significant weight loss noted in a short period and recommendations for weekly weight monitoring, there was a lack of documented weekly weights following the initial identification of weight loss. The resident experienced episodes of lethargy and decreased responsiveness, which were reported to providers and resulted in medication adjustments and hospital transfer. The development of multiple wounds, including pressure ulcers and DTIs, occurred despite the presence of care plans and physician orders intended to prevent such outcomes. The documentation reveals a failure to consistently assess and meet the resident's basic needs for skin integrity and nutrition, leading to the development of avoidable pressure injuries and related complications.