Failure to Prevent and Assess Pressure Ulcer Following Prolonged Bedpan Use
Penalty
Summary
A resident with multiple comorbidities, including atrial fibrillation, diabetes, congestive heart failure, chronic kidney disease, liver cirrhosis, peripheral vascular disease, bilateral below-the-knee amputations, and altered mental status, was admitted to the facility and required moderate staff assistance with toileting. The resident preferred the use of a bedpan and was cognitively intact prior to the incident. On the day in question, the resident experienced increased confusion, lethargy, and other symptoms suggestive of a urinary tract infection, for which treatment was initiated. During this period of acute illness, the resident was placed on a bedpan during the night shift and was not removed for an extended period of time, with documentation and interviews indicating the resident remained on the bedpan for at least 4.5 hours. Staff were unable to determine exactly which staff member placed the resident on the bedpan or the precise duration. Upon removal of the bedpan by day shift nurses, a deep tissue injury (DTI) in the shape of the bedpan was discovered on the resident’s buttocks, with subsequent hospital records confirming the presence of a DTI and associated skin breakdown. The facility’s investigation could not substantiate neglect but acknowledged the resident was on the bedpan longer than appropriate. Following the discovery of the DTI, facility staff failed to thoroughly assess and document the wound as required by facility policy. There was no immediate measurement or detailed documentation of the wound characteristics, and key clinical staff, including the nurse practitioner and DON, were not notified of the new skin impairment in a timely manner. The facility’s established procedures for new skin impairments, including incident reporting, wound measurement, and notification, were not followed when the injury was identified.