Failure to Identify and Treat Pressure Ulcers Resulting in Harm
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer program for a resident who was admitted with a history of skin breakdown. Upon admission, the resident's prior hospital records indicated an active coccyx pressure injury, but the facility's admission observation did not identify any skin alterations or document the existing wound. The care plan noted the resident was at high risk for pressure ulcers but did not include specific interventions or ongoing treatment for the known coccyx injury. Weekly and shift-based skin assessments were either not completed or not documented as required, and there was no evidence that the facility recognized or treated the resident's pressure injuries during their stay. Despite physician orders for pressure-reducing interventions such as floating heels, use of pressure-reducing cushions and mattresses, and regular turning and repositioning, there was no documentation that these interventions were carried out. Nursing and aide documentation was inconsistent, with aides noting open areas and dressings on the resident's buttock, while nursing records failed to acknowledge any wounds. The resident, who was dependent on staff for most activities of daily living and was incontinent, was not consistently assessed or provided with necessary wound care. Reports from the resident's spouse and staff interviews indicated that the resident was not changed in a timely manner and did not receive consistent care, further contributing to the lack of wound management. The deficiency resulted in actual harm when the resident was transferred to the hospital due to a change in condition and was found to have multiple pressure injuries, including an unstageable sacral wound with necrotizing soft tissue infection, and additional pressure injuries to the right buttock, heel, and upper posterior right leg. Hospital records confirmed the presence and progression of these wounds, which were not identified or treated by the facility. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's wounds, and a failure to follow the facility's own policy for pressure injury prevention and treatment.