Failure to Accurately Assess, Treat, and Monitor Pressure Ulcers Resulting in Infection and Hospital Transfer
Penalty
Summary
A resident with a history of a displaced intertrochanteric fracture of the left femur and osteomyelitis was admitted to the facility and identified as being at risk for skin breakdown due to functional mobility decline and bladder incontinence. Initial assessments, including the Braden scale and MDS, indicated the resident was at risk for pressure ulcers but had no unhealed pressure ulcers at admission. However, within days, the resident developed moisture-associated skin damage (MASD) and bruising on the buttocks, which was attributed to frequent bedpan use and anticoagulant therapy. Despite these findings, there was no documentation of a thorough medical provider assessment of the skin impairments at this stage. Subsequent progress notes and wound assessments documented the development and worsening of pressure ulcers on the resident's buttocks, including the emergence of unstageable wounds with slough and eschar. Physician orders for wound care, such as Triad paste and Medihoney, were issued, but there were missed treatments documented in the medication administration records, including missed applications of Triad and Medihoney, as well as missed doses of Vitamin C due to unavailability. Enhanced barrier precautions to prevent infection were not implemented until several days after the wounds were identified, and care plan updates for the new pressure ulcers were delayed. Throughout the resident's stay, there was a lack of timely and complete wound assessments by medical providers, with nursing staff documenting wounds as present on admission despite conflicting evidence. The nurse practitioner confirmed that they did not conduct thorough wound assessments or participate in treatment planning, instead relying on nursing staff to write and later sign off on treatment orders. The resident's wounds became infected, leading to pain, functional decline, and ultimately an acute care transfer to the hospital. There was no documentation that the development of the pressure ulcers was unavoidable, nor was there evidence of comprehensive provider assessment of the wounds prior to the resident's transfer.