Failure to Notify Responsible Party of Worsening Pressure Ulcer
Penalty
Summary
Facility staff failed to notify the responsible party when a resident’s sacral pressure ulcer worsened. The resident was admitted from the hospital with multiple skin injuries, including an unstageable sacral pressure ulcer, and had diagnoses such as COPD, peripheral vascular disease, and pressure-induced deep tissue damage to the right heel and another site. The sacral pressure ulcer was documented as resolved and later reopened, at which time a Change in Condition form indicated that the responsible party was notified in person, and the wound consultant assessed the reopened ulcer as a Stage 3 pressure ulcer. The wound consultant continued weekly evaluations, and the resident was later transferred to the hospital for a change in condition and then returned to the facility. Following the resident’s return, the wound consultant evaluated the sacral ulcer again and documented that it had worsened to a Stage 4 pressure ulcer, and a new treatment order for Santyl and calcium alginate dressing was implemented. However, review of the clinical record did not show any documentation that the responsible party was informed of this worsening of the sacral pressure ulcer. In an interview, the DON stated that her expectation was that nursing staff notify the responsible party of any change in condition, and that worsening of a pressure ulcer to Stage 4 was considered a change in condition for which the responsible party should have been notified. After further review of the record, the DON confirmed there was no documentation that the responsible party had been notified of the worsening pressure ulcer.
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