Failure to Implement Comprehensive Pressure Ulcer Prevention and Care
Penalty
Summary
A cognitively impaired resident with multiple comorbidities, including diabetes, peripheral vascular disease, and a recent surgical amputation, was admitted to the facility with a documented skin alteration to the coccyx. Upon admission, there were inconsistencies in the assessment and documentation of the resident's skin condition, with records alternately describing the area as moisture-associated skin damage (MASD), an open area, and an unstageable pressure ulcer. The initial assessments failed to provide a comprehensive description, staging, or measurements of the wound, and there was no clear photographic evidence to support the presence or stage of a pressure ulcer. Despite care plans and physician orders for skin care interventions, such as the application of Triad paste and HydraGuard, there was no documented evidence that staff consistently provided or encouraged turning and repositioning every two hours as required. Additionally, the facility failed to ensure timely notification and involvement of the wound nurse and wound physician when the skin alteration was first identified. The wound physician was not made aware of the resident's condition until several days after admission, and the wound nurse was not notified at all during the initial period. Weekly skin assessments and wound documentation were either incomplete or missing, with staff failing to document wound descriptions, measurements, or photographs as required by facility policy. The lack of comprehensive assessment, documentation, and timely intervention led to the deterioration of the resident's skin condition, resulting in the development of an unstageable pressure ulcer with necrosis that required debridement. The facility's failure to implement a resident-centered plan for the prevention and treatment of pressure ulcers, including appropriate assessment, documentation, and communication among staff and consulting clinicians, directly contributed to actual harm to the resident.