Failure to Timely Identify, Assess, and Treat a High-Risk Resident’s New Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to timely identify, assess, document, and initiate treatment orders for a newly developed pressure injury in a resident who was quadriplegic, non-verbal, totally dependent on staff for all care, and at high risk for pressure injuries. The resident had a history of a facility-acquired Stage 2 ischial pressure ulcer that had healed and was on hospice care, with existing orders for a wedge cushion and low air loss mattress. Braden Scale assessments showed the resident progressed from moderate to high risk for pressure injury development, and the resident preferred lying on the left side, had a prior healed wound in the same area, and was dependent on staff for repositioning. On one night, a CNA reported to the night RN that the resident had a wound on the buttocks, described as red and bleeding on the ischium. The RN acknowledged being notified but did not assess the wound, did not apply or ensure a dressing was in place, did not document the wound in the medical record, and only verbally notified the wound nurse the following morning. The wound nurse later stated that any new wounds should be reported to her so she can assess, photograph, notify the physician and family, and obtain treatment orders, but confirmed she was not notified by nursing staff and instead learned of the wound from an aide. The EHR contained no documentation of the left ischial pressure area on the date the night RN was notified. When the wound nurse assessed the resident the next day, she found a large deep tissue injury on the left ischium measuring 12 cm by 9 cm, with maroon discoloration, blood-filled blister, moderate serosanguineous drainage, and peri-wound erythema, maceration, and bogginess, and noted there was no dressing on the area. Subsequent wound progress notes documented the injury as a deep tissue injury and later as an unstageable pressure injury with full-thickness skin and tissue loss. Staff interviews reflected confusion about how the wound became so large in a short time, acknowledgment that the resident was at great risk due to immobility and prior skin breakdown, and recognition that the resident should have had a protective dressing to the ischial area and that new wounds were to be immediately reported, assessed, documented, and communicated per facility policy on treatment and services to prevent and heal pressure injuries.
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