Failure to Implement Comprehensive Pressure Ulcer Prevention and Timely Infection Management
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for a resident admitted with two Stage IV pressure ulcers. Despite being identified as at high risk for impaired skin integrity due to multiple diagnoses including quadriplegia, malnutrition, and prior osteomyelitis, the resident experienced a deterioration in wound status, including increased wound size and signs of infection such as green drainage. Although wound cultures were ordered when infection was suspected, there were significant delays in obtaining and processing these cultures, with a two-week gap between the initial failed culture and the subsequent successful collection. During this period, the wounds continued to worsen, and appropriate interventions were delayed. The resident's care plan included interventions such as use of barrier creams, pressure reduction devices, repositioning, and wound care per physician orders. However, documentation and interviews revealed inconsistent implementation and monitoring of these interventions. Staff interviews indicated that the resident was sometimes non-compliant with off-loading and repositioning, but there was insufficient documentation of educational efforts or follow-up regarding non-compliance. Additionally, the facility lacked a policy on wound cultures, contributing to the delay in obtaining necessary diagnostic information and initiating timely treatment for infection. As a result of these failures, the resident's wounds became infected, with cultures eventually revealing multiple bacteria including MRSA and carbapenem-resistant organisms. The resident developed osteomyelitis and required hospitalization after experiencing confusion, lethargy, and overall decline. The deficiency was substantiated by medical record review, staff interviews, and the absence of timely and effective wound management practices.