Failure to Provide Timely Pressure Ulcer Assessment and Care
Penalty
Summary
A resident with multiple sclerosis, depression, and generalized weakness, who was cognitively intact, experienced a significant lapse in pressure ulcer care following a hospital admission for stroke-like symptoms. Upon return to the facility, the resident had a sacral wound with specific wound care instructions from the hospital, but there was no documented evidence that new wound care orders were entered or that the wound was properly assessed and treated from the time of readmission through several weeks. Nursing documentation was inconsistent, with gaps in dressing changes, skin checks, and provider assessments. The wound was not seen by a provider or the wound care team for an extended period, despite staff being aware of the open area and pain reported by the resident. The facility's policy required comprehensive skin assessments, weekly skin checks, daily visual checks by CNAs, and prompt notification and documentation of new skin issues. However, these protocols were not followed. Staff failed to notify the wound care team or medical providers in a timely manner, and incident reports were not consistently initiated for new or worsening wounds. Communication among staff was fragmented, with some nurses and providers unaware of the resident's condition or missing documentation of assessments and interventions. The resident's wound deteriorated from a Stage 1 to a Stage 4 pressure injury, with increasing pain and signs of infection, ultimately requiring sharp debridement during a subsequent hospitalization. Interviews with staff revealed confusion about reporting requirements, inconsistent practices regarding skin checks and incident reporting, and missed opportunities for timely intervention. The resident reported prolonged periods in bed due to lack of assistance, contributing to the worsening of the wound. Observations confirmed that pain was not addressed during wound care. The cumulative failures in assessment, documentation, communication, and timely intervention resulted in actual harm to the resident and placed other residents with pressure ulcers at risk for serious harm.
Removal Plan
- All residents with pressure ulcers were reassessed and treatment plans were reviewed for appropriateness.
- The Skin Care Program policy and procedure was revised to include all new admissions and readmissions would be screened by a member of the wound care team to ensure appropriate skin care treatment plan was initiated.
- Wound Care staff received re-education on the revised policy and procedure.