Failure to Identify, Assess, and Treat Stage 2 Penile Pressure Ulcer on Admission
Penalty
Summary
A resident was admitted to the facility with a documented Stage 2 pressure ulcer located on the left lateral meatus of the penis, as indicated in the admission and discharge paperwork from the previous facility. The documentation included specific orders to apply triple antibiotic ointment every shift with catheter care and to consult the Resident Care Manager if the wound worsened. However, upon admission, the facility failed to identify, assess, treat, or monitor the pressure ulcer. The resident's initial skin assessment, care plan, physician orders, and subsequent clinical records did not mention the presence of the pressure ulcer or any related treatment. Throughout the resident's stay, there was no documentation in the medical record or treatment administration records regarding the penile pressure ulcer. Multiple staff members, including CNAs and nurses, observed signs of injury such as bleeding, a tear, or a split on the penis during perineal or catheter care, but these observations were either not documented or not followed up with appropriate assessment and intervention. The resident also reported discomfort and requested to see a urologist, but there was no evidence that these concerns were addressed. Progress notes and care plans continued to omit any reference to the pressure ulcer or its management. The resident was eventually hospitalized, where it was discovered that the Foley catheter had caused significant erosion of the penile tissue, resulting in traumatic hypospadias and permanent loss of normal urinary function. Hospital records and interviews with hospital staff confirmed that the injury was consistent with prolonged catheter-related pressure and not an acute event. Facility leadership and care management staff were unaware of the pressure ulcer at the time of the survey, despite its documentation at the prior facility and multiple staff observations during the resident's stay.