Failure to Provide Timely Pressure Ulcer Assessment and Care
Penalty
Summary
A resident with multiple comorbidities, including diabetes, acute kidney failure, and impaired mobility, was identified as being at risk for pressure ulcers and was dependent on staff for bed mobility. The resident was initially assessed as having no pressure ulcers and was placed on a care plan that included regular skin assessments, use of pressure-reducing devices, and frequent repositioning. On a later date, a Stage 2 pressure ulcer was identified on the resident's sacrum, along with deep tissue injuries to the upper posterior thighs. Physician orders were obtained for wound care, including cleansing, foam dressing, turning every two hours, and use of a gel cushion. However, there was no documented evidence of wound assessments or monitoring from the time the ulcer was first identified until nearly three weeks later, despite facility policy requiring regular RN wound assessments. During this period, the resident's condition was not adequately monitored or reassessed by a registered nurse, and the wound care team did not evaluate the resident until a significant delay had occurred. Progress notes from nurse practitioners documented visits for unrelated issues, but did not mention the resident's skin condition or pressure ulcers. When the wound care physician finally assessed the resident, two Stage 3 pressure ulcers were identified, indicating a progression of the wounds. There was also a lack of documentation regarding wound progression for an additional week, and no evidence that the care plan was reviewed or revised in response to the resident's deteriorating skin condition. The resident was eventually hospitalized for worsening pressure ulcers, with hospital records describing extensive wounds with both partial and full thickness ulcerations, necrotic tissue, and a large affected area. Interviews with facility staff revealed uncertainty about wound assessment responsibilities, frequency, and documentation requirements. Staff acknowledged that wound assessments were not performed as required and that the wound care team visit was delayed, in part due to a COVID-19 outbreak. The delay in assessment and lack of documentation resulted in actual harm to the resident, as the pressure ulcers progressed in severity before appropriate interventions were implemented.