Failure to Assess, Monitor, and Treat Pressure Ulcer Results in Worsening Wound
Penalty
Summary
A resident with reduced mobility and type 2 diabetes was identified as being at high risk for skin breakdown, as indicated by a Braden score of 11. The resident's care plan included multiple interventions for skin integrity, such as the use of an alternating pressure mattress, barrier cream, regular turning and repositioning, and daily skin monitoring. Despite these interventions being listed, the care plan was not updated upon the resident's re-admission, and there was a lack of follow-through in implementing and documenting appropriate wound care interventions. On assessment, the resident was found to have a wound on the coccyx, initially documented as moisture-associated skin damage (MASD) with incontinence-associated dermatitis (IAD). The wound was present on admission, but no treatment orders were obtained or implemented for this wound. Staff interviews revealed that both nursing assistants and nurses observed an open area on the coccyx, described as red and larger than a quarter, but the nurse who assessed the wound did not notify the provider or obtain specific treatment orders. Instead, a barrier cream and gauze were applied without clear documentation of the type of cream used, and the provider was not informed to establish a formal treatment plan. Further review showed that the wound worsened, as documented during a subsequent hospital visit, where multiple chronic shallow pressure ulcers were noted, and the coccyx wound was described as much worse than previously observed. The wound care provider confirmed not having assessed the resident, and the facility's own guidelines required provider-ordered treatments for wounds, which were not followed. The Director of Nursing and Assistant Director of Nursing acknowledged that treatment orders were missed and that the wound care team had not seen the resident as expected.