Failure to Prevent and Manage Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to develop and update an individualized care plan and did not ensure that a resident at high risk for skin breakdown received appropriate treatment and services to prevent the development and worsening of a pressure ulcer. The resident, who had multiple medical diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, cognitive communication deficit, depression, and hypertension, was admitted with intact skin but was identified as high risk for skin breakdown based on a Braden scale score of 12. Despite this, the care plan was not updated with new interventions after a skin impairment was reported, and preventive measures such as turning and repositioning every two hours were not consistently implemented, especially when the resident was in a wheelchair. Staff interviews and record reviews revealed that the resident was dependent on staff for repositioning and hygiene, requiring two staff members for transfers and repositioning. Multiple staff members, including CNAs and LPNs, acknowledged that the resident was not always repositioned every two hours while in the chair, sometimes remaining seated for more than four hours. There was no documentation of the resident refusing care, and social services were not notified of any refusals. The wound care nurse and other staff were aware of the resident's high risk and the need for frequent repositioning, but the interventions remained unchanged even after the development of a new wound. The wound was noted to have an odor for about a week before the resident was sent to the hospital, and the care plan was not individualized or updated to address the new wound. The resident's condition deteriorated, with the sacral wound progressing from a small opening to an unstageable pressure ulcer with necrotic tissue, ultimately requiring hospitalization for sepsis and necrotizing fasciitis. Hospital records documented a stage 4 sacral decubitus ulcer with extensive tissue destruction and infection, necessitating surgical debridement. Facility policies required turning and repositioning as part of pressure injury prevention and evidence-based wound treatment, but these were not consistently followed or documented. The lack of timely and individualized interventions, failure to update the care plan, and inconsistent implementation of preventive measures directly contributed to the resident's development and worsening of a severe pressure ulcer.