Failure to Prevent Worsening and Infection of Pressure Ulcer Due to Lapses in Assessment and Documentation
Penalty
Summary
The facility failed to prevent the worsening of a pressure ulcer for a resident with multiple comorbidities, including dementia, heart failure, diabetes, and chronic kidney disease. The resident developed pressure ulcers on multiple sites, most notably the right heel, which deteriorated from an unstageable deep tissue injury to a Stage IV ulcer with infection. Documentation shows that the wound increased in size, developed slough and eschar, and became infected, as evidenced by foul odor, drainage, and a positive wound culture for Streptococcus agalactiae. The resident experienced pain during wound care, and antibiotics were started after infection was confirmed. There were significant lapses in wound assessment and documentation. Weekly Pressure Ulcer Records were missing for extended periods, specifically from early August to late September, and there was no documentation of wound status or refusal of care during this time. The Treatment Administration Record indicated that wound care was being provided, but there was no corresponding assessment or progress documentation. Staff interviews revealed that there was no dedicated Wound Nurse during a critical period, and nurse managers were responsible for wound care without clear oversight or knowledge of the resident's wound status. The current CNO and Nurse Manager were not present during the period in question and could not provide information about the care provided. Delays in obtaining specialist wound care further contributed to the deficiency. A referral to a wound clinic was made in late September, but due to administrative confusion regarding the resident's veteran status and required transfer of care, the appointment was not scheduled until early November. During this time, the resident's wounds continued to deteriorate, and the wound clinic physician was unable to perform debridement due to the resident's pain. The lack of timely assessment, documentation, and specialist intervention resulted in the resident suffering harm from a worsening, infected pressure ulcer.