Failure to Implement Hospice Skin Care Plan and Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement end-of-life and hospice skin care plan interventions for a resident who was at very high risk for skin breakdown and was dependent on staff for all mobility. The resident had multiple diagnoses, including dementia, COPD, severe malnutrition, diabetes, and was re-admitted to the facility with an existing sacral pressure ulcer. Upon re-admission, hospice services were initiated, and the hospice plan of care included specific wound care instructions and the use of an alternating pressure pad. Despite these orders, the facility did not ensure that the prescribed pressure-relieving mattress or overlays were placed on the resident's bed, and the wound care interventions were inconsistently applied. Multiple staff interviews and record reviews revealed that the hospice-provided air mattress overlay was never implemented, with conflicting explanations from staff regarding its safety and appropriateness. The Director of Nursing (DON) and other staff members acknowledged that the overlay remained unused in the resident's closet, and there was no documentation of efforts to obtain or use alternative pressure-relieving surfaces in a timely manner. Additionally, weekly wound assessments and documentation were not consistently performed, and there were lapses in monitoring and dressing the resident's wounds as required by both facility policy and the hospice care plan. The resident's family, who had medical experience, also reported concerns about the lack of appropriate wound care and the absence of a dressing on the sacral wound. As a result of these failures, the resident developed multiple new in-house acquired pressure ulcers in addition to the original wounds, as documented in the facility's records and confirmed by staff and hospice personnel. The facility's own policies required individualized interventions, regular skin assessments, and coordination with hospice providers, but these were not followed. The lack of timely and appropriate interventions directly contributed to the resident's skin breakdown and the development of additional pressure ulcers prior to the resident's death.