Failure to Prevent and Timely Treat Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and monitor the skin integrity of a resident who was admitted without pressure ulcers but was identified as high risk for developing them due to factors such as bowel and bladder incontinence, limited mobility, and decreased ability to perform activities of daily living. Despite a care plan and physician orders in place for preventive interventions, including the use of a pressure reduction device and application of barrier cream, staff did not consistently implement or document these interventions. Notably, after the resident returned from a hospital stay, a wound nurse practitioner assessed the resident and provided treatment orders for incontinence-associated dermatitis, but these orders were not carried out for several days. During this period, the resident's skin condition deteriorated, with red areas and bleeding noted on the buttocks, and the development of two pressure ulcers: a stage III ulcer on the sacrum and a stage II ulcer on the left buttock. Documentation revealed that staff failed to identify and report these changes in a timely manner, and there was a lack of ongoing, comprehensive skin assessments as recommended by national guidelines. The resident was dependent on staff for turning, repositioning, and incontinence care, but these interventions were not consistently provided or documented according to the care plan and physician orders. Interviews with facility staff, including the wound nurse practitioner, LPN unit manager, and DON, confirmed that treatment orders were not implemented promptly and that the resident's wounds were avoidable with proper care. The failure to follow established protocols and timely implement provider-ordered interventions resulted in actual harm to the resident, who developed avoidable, facility-acquired pressure ulcers.