Failure to Identify and Document Pressure Ulcer Decline Resulting in Harm
Penalty
Summary
A deficiency occurred when facility staff failed to adequately and accurately identify, document, and respond to a significant decline in a resident's wound condition. The resident, who had diagnoses including Parkinson's disease, dementia, muscle weakness, and was dependent on staff for activities of daily living, was at risk for pressure ulcer development. Despite being identified as at mild risk for pressure ulcers and having a care plan that included interventions such as incontinence care, use of barrier cream, and weekly skin evaluations, the resident developed a wound that was initially documented as moisture-associated skin dermatitis (MASD) rather than a pressure ulcer. Wound assessments and progress notes indicated that the wound was described as MASD and treated accordingly, with no additional interventions implemented to address the resident's large, soft stools or to prevent prolonged moisture exposure. Staff interviews and text messages revealed that nursing staff were instructed to continue documenting the wound as MASD, despite observations that the wound had characteristics of a pressure ulcer, including necrosis, foul odor, and significant decline in condition. The wound nurse lacked official training or certification, and there was a lack of escalation or notification to the physician or responsible party regarding the true nature and severity of the wound. The resident was eventually transferred to the hospital with altered mental status, dehydration, malnutrition, and an unstageable pressure ulcer to the coccyx, which was found to be necrotic and infected. Hospital records and family interviews confirmed that the wound was severe and required surgical intervention, but the family declined surgery and opted for palliative care. The resident was admitted to hospice and subsequently passed away. The facility's failure to accurately assess, document, and communicate the decline in the resident's wound resulted in actual harm, as evidenced by the resident's hospitalization and subsequent death.