Failure to Assess, Document, and Treat Pressure Ulcer on Right Heel
Penalty
Summary
A resident with a history of anemia, Type II diabetes mellitus, and chronic kidney disease was admitted to the facility with multiple wounds, including a left below-the-knee amputation, a stage IV pressure ulcer, a stage III pressure ulcer, and a venous ulcer. Upon admission, the resident was noted to have black eschar on the right heel and second toe, but there was no evidence that these wounds were assessed, described, or measured. Physician orders for offloading pressure boots and daily skin prep to the right heel were in place, but documentation showed inconsistent application and monitoring of these interventions, with several days lacking evidence of treatment or documentation of refusals. Throughout the resident's stay, required skin assessments and wound documentation were not completed as ordered. Skin observation tools and progress notes repeatedly failed to assess or mention the right heel pressure ulcer, and weekly skin checks were not consistently performed or documented. When a new open wound was discovered on the right heel, there was no immediate documentation of the wound's characteristics, and the new treatment order was not initiated until two days later. Wound care notes and treatment administration records did not reflect timely or complete implementation of physician-ordered treatments for the right heel wound. The resident was eventually transferred to the hospital, where the right heel wound was found to be gangrenous and infested with maggots. Interviews with facility staff confirmed that the right heel wound was not monitored or assessed from admission until it was seen by the wound care physician, and that required treatments and interventions were not consistently documented or performed. Facility policy required ongoing assessment and documentation of wound care, but these procedures were not followed for the resident's right heel pressure ulcer.