Failure to Timely Identify and Assess Pressure Injuries
Penalty
Summary
The facility failed to identify two areas of pressure injury on a resident until the wounds became unstageable. The resident, who had diagnoses including Type 2 Diabetes Mellitus, peripheral vascular disease, and existing stage three and stage four pressure ulcers, was cognitively intact and required moderate assistance with personal hygiene. Despite physician orders for skin checks to be completed twice weekly, new pressure areas on the resident's left and right buttocks were not detected until they had progressed to unstageable wounds, as documented in wound assessment reports. One of these wounds required debridement and was subsequently classified as a stage four pressure injury, while the other was identified as a stage three pressure injury. Interviews with facility staff revealed that the resident preferred to remain seated in a wheelchair throughout the day, often using a bedpan in the chair and refusing showers, which limited opportunities for staff to observe the skin on the buttocks. The Assistant Director of Nursing acknowledged that the new pressure ulcers should have been identified before reaching advanced stages. The DON confirmed that staff responsible for the resident's care were also responsible for conducting skin checks. The wound care physician noted that the resident's constant sitting and reluctance to move contributed to the development of the pressure ulcers, and that the wounds were already advanced when first assessed.