Failure to Identify and Treat Pressure Ulcers Before Progression to Stage III
Penalty
Summary
The facility failed to identify and treat pressure ulcers before they progressed to Stage III for two residents. For one resident with severe cognitive impairment, multiple comorbidities, and who was dependent on staff for all activities of daily living, a coccyx wound was not documented or identified in care records or shower sheets prior to being found as a Stage 3 pressure ulcer with undermining and drainage. The wound was not present on admission, and there was no indication in the records that staff had observed or reported any skin issues in the weeks leading up to its identification. The facility wound nurse confirmed that the wound should have been identified before reaching this advanced stage. Another resident, who was cognitively intact and had diagnoses including anemia, heart failure, wound infection, and diabetes, developed a Stage 3 pressure ulcer on the right lateral ankle. The wound was not documented in the clinical record or on shower sheets prior to being identified as a Stage 3 ulcer. Although there were physician orders for weekly skin inspections and wound care, there was no documentation of the wound or its treatment until after it had progressed to Stage 3. Interviews with nursing staff confirmed that the wound should have been identified earlier, and the facility's own policy required daily observation and reporting of skin issues, which was not followed in these cases.