Failure to Prevent and Manage Pressure Ulcers Resulting in Harm
Penalty
Summary
A resident was admitted to the facility with multiple complex medical conditions, including a cervical vertebral fracture with surgical intervention, impaired mobility, idiopathic peripheral autonomic neuropathy, ankylosing spondylitis, cirrhosis of the liver, muscle weakness, and neuromuscular dysfunction of the bladder. Upon admission, a full body assessment was completed, and no open skin areas were noted on the buttocks. The resident was identified as being at mild risk for skin breakdown, and standard interventions such as turning and repositioning every two hours were implemented. Despite these interventions, a stage 2 pressure ulcer was identified on the resident's left buttock three days after admission. The facility failed to implement effective interventions to prevent the progression of the pressure ulcer, and weekly wound measurements and detailed documentation were not consistently performed as required by professional standards and facility policy. The treatment nurse did not measure the wound weekly, and there was a gap in wound assessment and documentation from late May to early June. During this period, the wound worsened, and a second wound developed on the right buttock. The wound specialist was not consulted until over a month after the initial wound was identified, and by that time, the left buttock wound had become unstageable and the right buttock had developed shearing and a new pressure ulcer. The lack of timely and thorough wound assessment, documentation, and intervention led to the progression of the resident's wounds to stage 4 pressure ulcers, resulting in pain, suffering, and loss of mobility. The resident reported that the wounds interfered with his ability to participate in physical therapy and rehabilitation, leading to a decline in his physical and emotional well-being. The resident ultimately decided to discharge home with ongoing wound care needs, including a wound vac, after expressing concerns that the facility did not act promptly to address his wounds or psychosocial needs.