Failure to Report and Treat Decline in Pressure Ulcer
Penalty
Summary
A resident with diagnoses including cerebral infarction and multiple myeloma, who was dependent on staff for all activities of daily living, was admitted with a sacral stage IV pressure ulcer. On 10/24/25, a wound consultation documented the ulcer as full-thickness with moderate exudate but no signs of infection or inflammation. However, a skin issues note from the same day described purulent exudate and a moderately saturated dressing, indicating the presence of pus. The resident's care plan required monitoring for significant changes in the wound and notifying the physician of any such changes. Despite these findings, there was no documentation that the physician or wound clinician was notified of the purulent drainage. No further documentation regarding the sacral wound was found between 10/24/25 and 10/29/25, when the resident was transferred to the hospital. Hospital records indicated the presence of a stage IV decubitus ulcer with surrounding erythema and purulent discharge, and wound cultures revealed infection with Methicillin-Sensitive Staphylococcus aureus and Pseudomonas aeruginosa. Facility staff, including the wound nurse and DON, confirmed they were not informed of the purulent drainage prior to the resident's hospital transfer, and no additional explanation or documentation was provided.