Failure to Identify and Treat Pressure Ulcer Resulting in Amputation
Penalty
Summary
A seventy-six-year-old woman with multiple comorbidities, including Type 2 diabetes, metastatic cancer, and recent hip replacement, was admitted to the facility. Upon admission, her hospital records documented a pressure injury to the right heel, but the facility's admission assessment did not identify any wounds, and she was marked as bed bound. Weekly skin assessments were inconsistently documented, with some entries indicating existing skin alterations and others not specifying the location or using unclear abbreviations. The resident was dependent for mobility and at high risk for pressure ulcers, but the care plan interventions, such as floating heels and a pressure redistribution mattress, were not consistently implemented or documented. The resident began to complain of foot pain, which she reported to nurses, the NP, and PT staff over several weeks. Despite these complaints, the wound on her right heel was not promptly or accurately identified. When a blister on her heel burst during physical therapy, it was initially treated as a simple blister rather than a pressure ulcer. The wound care nurse (WCN) did not consult the wound care nurse practitioner (WCNP) immediately, and there was confusion and lack of documentation regarding the wound's assessment and treatment. The wound progressed to a necrotic state with signs of infection, including odor and increased size, but wound care was not provided daily as ordered, and documentation of care was inconsistent. The resident and her family reported that wound care was infrequent, and the mattress provided was uncomfortable and not replaced despite complaints. The wound continued to deteriorate, and the resident was eventually admitted to the hospital with a necrotic pressure ulcer requiring possible amputation. Hospital staff found the wound to be unstageable due to extensive slough and necrosis. Interviews with facility staff revealed lapses in communication, assessment, and documentation, including failure to complete required SBAR assessments and progress notes. The WCN and ADON acknowledged gaps in their documentation and assessment processes, and the WCNP confirmed that the wound was not seen promptly after it opened. Ultimately, the resident underwent an above-the-knee amputation due to the infected pressure ulcer.
Removal Plan
- Skin sweep of all residents to assess for any worsening or unidentified pressure ulcers to identify and provide treatment to all pressure ulcers. The skin sweep was completed by RDCS, DON, DON #2, UNIT MANAGER, and Treatment Nurse with no new findings or negative outcomes.
- Conduct Emergency QAPI meeting regarding pressure ulcers including notification to the medical director.
- RDCS/DON/Designee audit new admissions and readmissions to ensure any pressure injuries are identified appropriately, prevention measures in place, and treatment orders, as applicable.
- Complete in-services regarding pressure ulcers for all licensed nursing staff including head to toe skin assessments, newly identified wounds will be assessed and documented with notifications to RP and medical provider, skin assessment will be completed by charge nurse or treatment nurse for any new admission or readmission, and treatment orders will be obtained as applicable.
- Implement quick interventions to prevent further breakdown of identified pressure ulcers by providing air mattresses for residents as applicable.
- Each Licensed Nurse will complete a post-test after their education is completed to ensure staff comprehend in-services. If the employee does not pass the test with at least 90% correctly answered the staff member will be re-educated and re-tested until at least 90% pass rate is met.
- DON/Designee will utilize a staff roster to ensure 100% compliance with education. Licensed nurses will not be allowed to work until in-services are completed by DON/Designee.
- Head to toe skin assessments of all residents will be completed by the Director of Nursing (DON), Treatment Nurse, Assistant Director of Nursing (ADON), and Regional Compliance Nurse.
- All newly admitted residents will have a head-to-toe skin assessment completed by the licensed nurse or treatment nurse and verified by the DON/Designee to ensure all pressure ulcers are identified upon admission and readmission and ensure appropriate treatment.
- Nursing staff will be in-serviced by the RDCS, DON, ADON, UM and Treatment Nurse on these protocols.
- Clinical staff will not be allowed to work their scheduled shift until they have completed all education related to the IJ.
- The Treatment Nurse or Nurse Manager designee will complete a head-to-toe assessment and document in the EMR to validate the findings of the initial skin assessment.
- Head-to-toe assessments must be completed weekly.
- Any newly identified wounds will be addressed by the Treatment Nurse or Licensed Nurses to include assessment and documentation of the skin site and initiate appropriate clinical interventions.
- Notify the Patient's Representative and Medical Provider of any new or change in the existing wound(s) and document in EMR.
- A Wound Assessment will be completed by the Treatment Nurse or Licensed Charge Nurse and a narrative of each site will be documented weekly for any pressure injury.
- RDCS/DON will complete an audit of all findings to ensure implementation of skin system.
- Notify the Medical Director of the Immediate Jeopardy by Executive Director.
- Conduct emergency QAPI meeting.
- The Treatment Nurse will receive 1:1 education and counseling regarding identification of pressure ulcers including worsening of wounds and obtaining orders from the physician for appropriate treatments.
- The treatment nurse will present a clinical wound report every day during the Clinical Stand-Up Meeting.
- DON/Designee will monitor new admissions during daily clinical IDT Stand Up meeting to ensure skin assessments have been completed upon admission and interventions and treatment orders are in place, as applicable.
- RN Weekend Supervisor will monitor new admissions on the weekend to ensure skin assessments have been completed upon admission and interventions and treatment orders are in place, as applicable.
- Facility policies & procedures will be reviewed by the DON, RDCS, VP of Operations, VP of Clinical Services and Director of Education. The policies and procedures will be included in the staff in-servicing.