Failure to Prevent and Accurately Classify Facility-Acquired Pressure Ulcers
Penalty
Summary
A resident with multiple comorbidities, including diabetes, dementia, kidney disease, and heart disease, was admitted to the facility with no skin issues. Over the course of their stay, the resident developed three facility-acquired pressure ulcers: a Stage 3 ulcer on the coccyx, an unstageable wound on the left heel, and a deep tissue injury on the left lateral malleolus. The resident was non-ambulatory, required assistance for all activities of daily living, and was incontinent of bowel and bladder, with infrequent changes and prolonged periods between incontinence care. Facility staff, including CNAs and wound care nurses, observed and documented the wounds at various stages, but there were inconsistencies in the classification and documentation of the wounds. The wounds were initially identified as pressure injuries but were later reclassified multiple times as either moisture-associated skin damage (MASD) or diabetic/vascular ulcers, despite diagnostic imaging (doppler studies) showing no evidence of vascular insufficiency. The facility's wound care team and DON provided conflicting explanations for the reclassification, and there was a lack of clear, consistent documentation regarding the nature and progression of the wounds. Observations revealed that the resident was not consistently provided with off-loading devices, such as heel boots, and was often found with heels resting directly on the bed. Daily skin inspections and timely interventions, as outlined in the facility's own skin management policy, were not consistently documented or observed. Additionally, a new skin alteration was noted without corresponding documentation. These actions and inactions contributed to the development and worsening of the resident's pressure ulcers, as well as inconsistencies in wound assessment and care.