Failure to Identify, Assess, and Communicate Pressure Ulcers Resulting in Harm
Penalty
Summary
The facility failed to properly identify, assess, and document wounds for a resident with significant risk factors, resulting in the development and progression of pressure ulcers. The resident, who had a history of hemiplegia, diabetes with neuropathy, Parkinson's disease, and was bedfast with limited mobility, was admitted without skin issues but later developed skin breakdown on the buttocks that progressed to an unstageable pressure ulcer requiring surgical debridement. There was also a failure to assess and treat a Deep Tissue Injury (DTI) on the right heel, which was not identified or documented until brought to staff attention by the resident's representative. Staff did not consistently perform or document weekly skin assessments as ordered, and there were discrepancies in wound identification, staging, and communication among nursing staff, wound care providers, and the primary care physician. Documentation was lacking regarding the identification, measurement, and treatment of wounds, as well as notification of the primary care physician and the resident's representative. The care plan was not updated in a timely manner to reflect the resident's changing skin condition, and interventions such as the use of a low air loss mattress and offloading devices were not consistently implemented or documented. The resident's representative was not kept informed about the extent or severity of the wounds, leading to distress when she discovered the wounds herself. Interviews with staff revealed confusion about roles and responsibilities for wound documentation, notification, and care planning. There were also inconsistencies in the documentation of wound locations and descriptions, and a lack of follow-up on wounds identified during hospitalizations. The facility's failure to identify, assess, and communicate about wounds resulted in harm to the resident, including the need for surgical intervention.