Failure to Prevent and Monitor Stage 3 Sacral Pressure Ulcer
Penalty
Summary
This facility failed to provide necessary care and services to prevent the recurrence and worsening of a stage 3 sacral pressure ulcer for one resident. The resident was readmitted to the facility after hospitalization and initially had no pressure ulcers identified, but was noted to have moisture-associated skin damage (MASD). Shortly after readmission, a wound was identified on the sacrum, and wound care orders were initiated. However, there were gaps in wound care treatment orders and inconsistent documentation of wound care administration, with several dates lacking evidence that wound care was provided as ordered. Additionally, weekly wound assessments and measurements were not consistently performed or documented, and there was a period when the wound care physician did not monitor the wound. The resident's wound worsened over time, increasing in size and developing slough, indicating a decline in condition. Interviews with staff revealed that the previous wound care nurse had not been fulfilling job responsibilities, and the new wound care nurse had only recently assumed the position. The facility's documentation showed lapses in both assessment and treatment, including missing wound care documentation on multiple dates and a lack of wound management records after a certain point. These failures contributed to the recurrence and deterioration of the resident's stage 3 sacral pressure ulcer.