Failure to Provide Adequate Pressure Injury Services and Monitoring
Penalty
Summary
Facility staff failed to provide adequate pressure injury services for a resident, resulting in the development of new and worsening skin injuries. The staff did not accurately monitor or evaluate the resident's pressure injuries, nor did they revise treatment plans to promote healing. There was a lack of evaluation and monitoring of the impact of interventions intended to prevent new pressure injuries, and interventions were not implemented, monitored, or modified to address underlying risk factors. As a result, the resident developed new Moisture Associated Skin Damage (MASD) on the coccyx, a Stage II pressure injury on the coccyx, new open lesions on both rear thighs, and a Stage III pressure injury on the left heel, all of which developed while the resident was in the facility. The resident had multiple diagnoses that increased her risk for skin breakdown, including hemiplegia, hemiparesis, monoplegia, diabetes with peripheral angiopathy, muscle weakness, peripheral vascular disease, and incontinence. She was completely dependent on staff for mobility, hygiene, and dressing. Despite these risk factors, documentation showed that wound measurements were not consistently recorded, and there was a period when the facility lacked a designated wound nurse. During this time, floor nurses were responsible for wound care and weekly skin checks, but there was no routine schedule for physician or physician assistant review of wound care or treatment effectiveness. Communication and documentation regarding physician notification and reassessment of wounds were inconsistent or lacking. Interviews with staff revealed that interventions were not updated in response to new or worsening wounds, and care plans were not revised as required. Licensed nurses and CNAs reported that they were not involved in interdisciplinary team meetings, and there was no evidence that the resident or her family were included in care planning or educated about pressure injury prevention. Reports of the resident returning from outings with family in a wet condition did not result in changes to care interventions. Facility policy required interdisciplinary assessment and care plan updates for new pressure injuries, but these procedures were not followed. The lack of timely and appropriate interventions, monitoring, and care plan revisions directly contributed to the resident's skin injuries.