Failure to Provide Timely Incontinent Care and Repositioning Leads to Worsening Pressure Injuries
Penalty
Summary
A resident with a history of atherosclerotic heart disease, anxiety, depression, and hypertension, and who was assessed as having severe cognitive loss, was admitted to the facility and identified as being at risk for pressure ulcers. The resident's care plan included interventions for bladder incontinence and required that incontinent care be provided at least every two hours. Despite these interventions, the resident did not have any unhealed pressure ulcers at admission, and initial assessments indicated only redness to the buttocks with barrier cream applied. On two consecutive nights, certified nursing assistants (CNAs) failed to provide required incontinent care, turning, and repositioning for the resident, as confirmed by video footage showing no such care was given during overnight shifts. Staff interviews revealed that the CNAs were either short-staffed or too busy to provide care, and neither the charge nurse nor other staff were notified of the missed care. As a result, the resident's skin condition deteriorated, with a hospice nurse later identifying a stage II sacral wound, which progressed to include a right heel abrasion, a left heel blister, and a sacral wound with eschar within days. Documentation and progress notes were also missing for the period when the wounds developed. The facility failed to identify the new wounds prior to the hospice nurse's visit and did not initiate wound care orders promptly after the wounds were discovered. There was no system in place to ensure that CNAs were consistently turning and repositioning residents, and the charge nurses did not adequately monitor or document these interventions. The facility's own policy required regular skin assessments, timely notification of changes, and documentation, but these procedures were not followed, resulting in the resident's wounds worsening.