Failure to Identify and Treat Unstageable Pressure Ulcer
Penalty
Summary
A resident with severe cognitive impairment, multiple comorbidities including anemia, diabetes, traumatic brain injury, malnutrition, and respiratory failure, was identified as being at very high risk for pressure ulcers. The resident was dependent on staff for bed mobility and transfers, and the care plan acknowledged risk factors such as impaired mobility, cognition, incontinence, and high-risk medications. However, the care plan failed to address an unstageable pressure ulcer on the left heel and lacked specific interventions for repositioning, turning, or floating the heels to prevent further breakdown or promote healing. Clinical documentation revealed repeated failures to assess, document, and treat the left heel pressure ulcer. Upon multiple admissions and readmissions, progress notes and skin assessments either omitted mention of the wound or lacked essential details such as wound measurements, characteristics, and treatment interventions. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect any wound care or new interventions for the left heel ulcer until several weeks after the wound was first identified. Even after wound care orders were received from the hospital, there was no documentation of consistent implementation of repositioning, turning, or heel floating as required by facility policy. Interviews with the DON and NP confirmed gaps in wound assessment, documentation, and intervention. The DON acknowledged omissions in skin assessments and was uncertain about the timing of heel protector use. Facility policies required regular turning, repositioning, and heel floating for residents at risk of or with pressure ulcers, but these interventions were not documented in the care plan or medical record. The lack of prompt assessment, documentation, and implementation of appropriate interventions contributed to the failure to provide care consistent with professional standards for pressure ulcer prevention and management.