Failure to Reassess and Implement Pressure Ulcer Interventions
Penalty
Summary
A resident with a history of traumatic spinal cord dysfunction, neurogenic bladder, and quadriplegia, who was cognitively intact and required extensive assistance with all activities of daily living, developed a pressure ulcer after admission to the facility. The resident was identified as being at risk for pressure ulcers and had interventions in place, including regular skin assessments, use of pressure-reducing devices, and scheduled repositioning. Despite these interventions, the resident developed a deep tissue injury (DTI) on the coccyx within 11 days of admission. The resident reported refusing repositioning on the first or second night due to disturbances from staff and feeling unwell, but also stated that staff did not attempt to reposition him or offer assistance during a prolonged period in bed. Documentation and communication lapses were noted, as staff failed to consistently document refusals or the risks and benefits discussed with the resident. The initial identification of the wound was delayed. Although a nursing assistant noticed the sore and informed the nurse, the wound was not assessed by a nurse until several days later. The wound nurse was not notified in a timely manner, and the required documentation, including a progress note and wound tracker form, was not completed at the time the wound was first observed. The wound was eventually assessed and identified as a DTI, but the delay in assessment and documentation contributed to a lack of timely intervention and monitoring. Further deficiencies were observed in the implementation of wound care interventions. The resident's treatment plan required daily dressing changes, but these were not consistently performed over a weekend, as confirmed by both the resident and nursing staff. The nurse responsible for the dressing changes admitted to not completing them due to competing priorities and increased acuity on the unit. The lack of consistent wound care and failure to reassess and update interventions in response to the resident's condition and refusals contributed to the progression of the pressure injury.