Failure to Prevent, Identify, and Report New Pressure Ulcer
Penalty
Summary
A resident with multiple medical conditions, including hemiplegia, heart failure, and incontinence, was assessed as being at moderate risk for developing pressure ulcers. The resident required substantial assistance for bed mobility and was unable to reposition independently. Despite being identified as at risk, the facility failed to prevent, identify, report, and treat a new pressure ulcer that developed on the resident's sacrum. During a surveyor's observation, an open skin area approximately 2 by 2 inches with a red wound base was found on the resident's sacrum, covered only with barrier cream and without a proper dressing. Certified Nursing Assistant (CNA) staff observed the open wound during routine care but did not report it to the nursing staff as required by facility policy. The CNA initially claimed to have reported the wound but later admitted to assuming someone else had done so and ultimately did not notify the nurse. Licensed Practical Nurses (LPNs) and the Assistant Director of Nursing (ADON) were unaware of the wound prior to the surveyor's observation, and there was no documentation of the wound in the resident's electronic health record, progress notes, or skin assessments prior to the surveyor's findings. The wound care team and physician were not notified until after the surveyor brought the wound to the facility's attention. Facility records, including the resident's care plan and turning/repositioning program, indicated that staff were to check the resident's skin daily and report abnormalities. However, documentation from CNAs on shower/bath reports repeatedly indicated no new skin issues, and there was no record of the pressure ulcer in the days leading up to the survey. The facility's policy required prompt identification and reporting of skin alterations, but this process was not followed, resulting in a delay in assessment and treatment of the resident's pressure ulcer.