Failure to Implement Comprehensive Pressure Ulcer Prevention and Assessment
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for a resident who was at high risk for pressure ulcers due to multiple comorbidities, including severe protein-calorie malnutrition, diabetes mellitus, and limited mobility. The resident was dependent on staff for most activities of daily living, was always incontinent of urine, frequently incontinent of bowel, and had a history of a healed pressure ulcer to the coccyx. Despite these risk factors, the facility's plan of care and physician's orders included preventative measures such as pressure-reducing devices and a protective dressing to the coccyx, but there was a lack of effective ongoing monitoring and documentation regarding the condition of the skin under the dressing. Weekly skin assessments were documented as completed by nursing staff, but interviews and record reviews revealed that the dressing on the coccyx was not removed during these assessments, and there was no actual evaluation of the skin beneath the dressing. The wound nurse confirmed that the assessments were incomplete and that she was not notified of any new pressure ulcer development. The staff documented that dressing changes were performed as ordered, but there was no description of the skin's condition under the dressing throughout the resident's stay. The deficiency resulted in actual harm when the resident experienced an acute change in condition and was hospitalized. Upon hospital admission, the resident was found to have a Stage II pressure ulcer with extensive gas-forming soft tissue infection at the lower back, requiring surgical intervention. The hospital assessment indicated that the pressure ulcer had become infected during the resident's stay at the facility, and the facility's own staff and quality assurance nurse acknowledged that adequate and ongoing assessments were not completed.