Failure to Prevent and Identify Pressure Ulcers and Maintain Infection Control
Penalty
Summary
The facility failed to identify and intervene in the early stages of pressure injuries for two residents, resulting in the development and worsening of multiple facility-acquired pressure ulcers. One resident was admitted without a pressure injury to the coccyx, as documented on the admission skin check. However, a wound was later discovered on the coccyx that had already progressed to an unstageable pressure injury by the time it was identified. The wound measured 6.5 cm x 4.5 cm and contained both granulation and slough tissue. Staff interviews confirmed that skin checks were performed during showers and care, but the wound was not detected until it had reached an advanced stage. The resident was noted to have severe cognitive impairment and was dependent on staff for most activities of daily living, including mobility and hygiene, which increased the risk for pressure injuries. Another resident developed several facility-acquired pressure ulcers, including a stage 2 pressure ulcer on the right buttock, an unstageable pressure ulcer on the right great toe (later staged as a 2), a right heel ulcer that progressed from stage 2 to unstageable, and a stage 2 ulcer on the right groin. The right heel ulcer began as a blister, which ruptured and evolved into a wound with necrotic tissue, eventually being classified as unstageable. The resident had diabetes and edema, which contributed to the development of the blister. Documentation and staff interviews indicated that the resident was supposed to have both heels offloaded and be repositioned every two hours, but the resident reported that repositioning was not consistently performed. The care plan included interventions such as pressure relief mattresses, floating heels, and wound care, but these measures were not always implemented in a timely or consistent manner. During wound care observations, staff failed to follow proper infection control protocols. For example, a nurse did not change gloves between removing soiled dressings and applying clean ones, and used her finger to apply ointment directly to the wound. Supplies used during the dressing change were not handled in a manner that would prevent cross-contamination, as items were carried out of the resident's room and placed on common surfaces before being cleaned. Additionally, pressure reduction devices, such as offloading boots, were not reapplied after dressing changes, and soiled items were left in the resident's room. These lapses in infection control and pressure injury prevention contributed to the development and worsening of pressure ulcers in the affected residents.