Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
A resident with a history of a sacral pressure ulcer and high risk for skin breakdown was not provided with adequate care to prevent the worsening of pressure ulcers. The resident was observed lying flat on her back with her heels pressed against the bed surface, despite care instructions to elevate her heels and reposition every two hours. The resident reported pain and burning from a wound on her buttocks, and stated that staff did not always have the necessary cream available during care. Documentation showed a significant increase in the size of a right gluteal Stage 3 pressure ulcer over a short period, with the wound progressing from a small, stable area to a much larger, fragile, and declining wound with eschar and active bleeding. Staff interviews and observations revealed multiple lapses in care. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) were unaware of the resident's wounds, did not consistently check on the resident, and failed to maintain enhanced barrier precautions as required for infection control. The resident's wound was not covered with a bandage as ordered, and barrier cream was not always available or applied as needed. Incontinence care was not performed properly, with the resident experiencing repeated episodes of catheter leakage that left her clothing and bedding wet. Staff were observed pulling linens out from under the resident, which can cause shearing and further skin breakdown, and did not consistently use gowns and gloves as required. Further, there was a lack of communication and awareness among staff regarding the resident's wound status and care needs. Some staff had not seen the wound, and wound care orders were not consistently followed. The resident, who was cognitively intact, reported ongoing pain and inadequate care. The failure to provide proper wound care, repositioning, incontinence management, and infection control measures resulted in actual skin breakdown and worsening of the resident's pressure ulcers.