Failure to Provide Timely Pressure Injury Assessment and Interventions
Penalty
Summary
A resident was admitted with multiple diagnoses, including rheumatoid arthritis, heart failure, and a urinary tract infection, and was identified as being at risk for pressure injuries (PIs) upon admission. Initial skin assessments documented blanchable redness on the coccyx, and a barrier cream was applied. The care plan included general interventions for skin integrity, such as keeping skin clean and dry, but did not include specific interventions for pressure offloading or enhanced monitoring. No additional interventions were added to the care plan prior to discharge, despite the resident's high risk for PIs and dependence on staff for repositioning and activities of daily living. Several days after admission, an open wound was observed on the resident's coccyx, but there was no documentation of wound measurements, description, or staging at that time. Progress notes and care conferences failed to identify or address the new wound, and the Nutrition at Risk meeting did not recognize any current skin issues, even though the wound had been present for three days. Physician orders for wound care were obtained, but there was no timely documentation of wound assessment, measurements, or staging. It was not until nine days after the wound was first documented that a wound care specialist assessed the wound, diagnosing it as a Stage 3 PI. The wound later progressed to an unstageable PI, requiring debridement and hospital evaluation. Throughout the resident's stay, there was a lack of documentation and implementation of essential interventions such as pressure-relieving surfaces, repositioning schedules, and nutritional support. Interviews with staff revealed that the resident did not receive an air mattress or protein supplements, and repositioning was not documented until 21 days after the wound opened. Staff also reported the absence of facility policies or guidelines for PI prevention and management. The resident's condition declined, leading to hospital transfer for suspected wound infection. The failure to provide thorough skin assessments, timely provider notification, and appropriate interventions contributed to the worsening of the resident's pressure injury.