Failure to Prevent and Manage Pressure Injury Progression
Penalty
Summary
A resident with a history of cerebral palsy, severe cognitive impairment, and prior pressure ulcers developed a new stage 2 pressure injury on the gluteal cleft while in the facility. The facility failed to provide necessary care and services to prevent the progression of this wound, as evidenced by incomplete and untimely weekly wound assessments, lack of accurate documentation regarding wound location, and failure to update the care plan promptly when the new wound was identified. The resident's Braden Scale assessment, which should have been completed upon a significant change of condition, was not performed as required by facility policy. The resident's wounds were not consistently or accurately assessed, with missing measurements and unclear documentation about the specific locations of each wound. Orders for wound care were not always transcribed or implemented correctly, and there were discrepancies between physician and wound clinic orders. The resident did not have an adequate wheelchair cushion for offloading pressure, and the specialty bed was not set to the correct weight, both of which are critical interventions for pressure injury prevention and management. Additionally, the wound vac was not changed as ordered due to supply issues, and there was no documentation of follow-up with the wound clinic when this occurred. Staff interviews revealed confusion regarding the number and location of wounds, with some staff treating multiple wounds as a single area and failing to complete separate assessments for each. There were also missed care plan updates and Braden assessments, and issues with obtaining wound photos due to equipment problems. These failures resulted in the resident's stage 2 pressure injury progressing to a stage 4 infected wound with osteomyelitis, requiring advanced interventions including wound vac therapy, antibiotics, and a urinary catheter.
Removal Plan
- Educated staff on the facility's skin and wound assessment process, timely transcription and implementation of physician orders, what to do if supplies are unavailable, care plan updates, and Braden Scale assessments
- Wound physician to round with facility staff devoted to wound care
- Implemented new skin and wound assessment forms
- Implemented skin impairment/new pressure area audits