Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
A resident with multiple medical diagnoses, including a lumbar fracture, subdural hemorrhage, and severe cognitive impairment, was admitted to the facility and identified as being at risk for pressure ulcers. Despite this, the facility failed to implement and maintain necessary interventions to prevent the development of pressure ulcers. The resident required total assistance with all activities of daily living and was noted to be chairfast and incontinent, further increasing the risk for skin breakdown. Initial assessments documented some redness and bruising, but subsequent weekly skin assessments repeatedly indicated intact skin until a significant change was noted, including the development of blisters and open wounds on the sacrum and lower extremities. The facility did not provide a pressure-reducing mattress for 15 days after it was ordered, nor did it supply pressure-reducing heel boots for 11 days, despite the resident's high risk and the presence of developing wounds. During this period, the resident developed multiple pressure ulcers, including on the left foot, right lateral ankle, left hip, and sacrum. Documentation and interviews revealed delays in obtaining and applying essential support surfaces and offloading devices, as well as inconsistent implementation of repositioning and pressure relief measures. The resident's wounds progressed to unstageable and deep tissue injuries, with the sacral ulcer eventually becoming necrotic and infected. The lack of timely and consistent interventions led to the resident's transfer to an acute care hospital for surgical debridement of the sacral ulcer. Interviews with facility staff confirmed that there were delays in receiving ordered equipment and that staff education on wound care and repositioning was reactive rather than proactive. The resident's condition deteriorated, resulting in a recommendation for hospice care due to the severity of the wounds and overall poor prognosis.