Failure to Timely Identify and Assess Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent the worsening of wounds for a resident with multiple comorbidities, including Peripheral Autonomic Neuropathy, COPD, Rheumatoid Disease, AFIB, and Chronic Respiratory Failure. Upon re-admission, the resident was identified as being at risk for pressure ulcers, and initial wound assessments documented two wounds that were subsequently resolved. However, additional wounds on the heels were not identified or assessed until several weeks after re-admission, and a significant wound on the right posterior lower extremity was not detected during weekly skin checks but was later found during wound care rounds. The resident was eventually transferred to an acute care hospital due to altered consciousness and concerns about worsening wounds. Hospital assessments revealed multiple chronic wounds, including unstageable pressure injuries with necrotic tissue and foul odor, as well as areas of tissue loss and discoloration on the sacrum, hips, and lower extremities. Interviews with facility staff indicated that there were lapses in timely wound identification and assessment, and the wound care nurse was unable to explain the delays in recognizing and treating the resident's wounds.