Failure to Prevent and Manage Pressure Ulcer Resulting in Harm
Penalty
Summary
A resident was admitted to the facility with a stage II pressure ulcer to the sacrum, as documented by the hospital prior to admission. Upon admission, the facility completed a Braden scale assessment indicating moderate risk for skin breakdown and noted the presence of a sacral wound. However, the initial skin check lacked detailed assessment, measurement, or staging of the wound. The baseline care plan included several interventions for pressure ulcer prevention, but documentation shows inconsistent and incomplete wound assessments, with missing measurements, staging, and descriptions in the clinical record. There was also a lack of timely and clear communication with the physician regarding changes in the wound's condition. Over the following days, the wound worsened significantly, with documentation indicating the development of necrosis and expansion to the bilateral buttocks. The facility failed to consistently document weekly pressure ulcer assessments, and there was no evidence of a physician order for the use of a low air loss mattress (LLAM) until well after it was reportedly initiated. Staff interviews confirmed that the resident was dependent for all ADLs, including turning and repositioning, and that the wound increased in size and severity during the resident's stay. The wound eventually became unstageable, with 100% necrosis and purulent drainage, and the resident was ultimately hospitalized with sepsis, acute kidney injury, and a large sacral ulcer with suspected gangrene. Throughout the resident's stay, there were inconsistencies in wound documentation, lack of timely intervention, and failure to follow professional standards of practice for pressure ulcer prevention and management. The facility did not ensure that the resident received necessary treatment and services to prevent the development and worsening of pressure ulcers, resulting in significant harm to the resident.