Failure to Prevent and Manage Pressure Injury Progression
Penalty
Summary
A resident was admitted to the facility without a pressure injury (PI) and subsequently developed a PI on the sacrum during their stay. The PI was first identified as a Stage 2 injury, but over the course of 18 days, it progressively worsened to an unstageable PI and then to a Stage 4 PI with signs of infection. Throughout this period, nursing staff, including the wound care nurse (WCN/RN) and a registered nurse (RN A), failed to notify the resident's attending physician (AP) of the changes in the PI's condition, despite facility policy requiring physician notification for significant changes in a resident's condition. Documentation showed that the AP was not informed of the PI's worsening status until six days after it was first identified as a Stage 2 injury, by which time the injury had already deteriorated further. The WCN/RN performed a conservative sharp wound debridement (CSWD) on the resident's PI without obtaining a physician's order, and there was no documentation that the AP was notified about the procedure or the continued deterioration of the wound. Interviews with staff confirmed that the AP was not kept informed of the PI's progression or the lack of healing, and the AP stated that if they had been aware of the worsening condition, they would have referred the resident to a wound care physician. The AP also confirmed that no specific orders were given for the CSWD procedure. The facility's documentation and staff interviews revealed a breakdown in communication and failure to follow established policies regarding notification and wound care management. Two days after discharge from the facility, the resident was admitted to an acute care hospital with an infected PI, sepsis, and osteomyelitis of the sacrum. Hospital records indicated that the resident's family sought hospital care due to the non-healing and foul-smelling wound. The resident passed away at the hospital ten days later. The failure to provide timely and appropriate wound care, notify the physician of significant changes, and obtain necessary orders for wound procedures directly contributed to the resident's worsened condition and subsequent hospitalization.