Failure to Prevent and Properly Treat Pressure Ulcers on Resident’s Right Foot
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development and progression of pressure ulcers and to consistently provide ordered wound care for one resident with multiple right foot pressure injuries. The resident was admitted with multiple medical conditions including COPD, obesity, anxiety, mild neurocognitive disorder, neuromuscular bladder dysfunction, depression, anemia, hypothyroidism, insomnia, hypertension, sleep apnea, GERD, and osteoarthritis, and was cognitively intact per a recent MDS. The MDS documented one stage 3 pressure ulcer present on admission and one unstageable pressure ulcer that was not present on admission. Facility records identified three facility-acquired wounds on the right foot: an unstageable right heel wound attributed to a brace, an initially unstageable right superior heel wound that progressed to a stage 3 pressure ulcer, and an unstageable right medial malleolus wound, all with documented increases in size over time. The medical record showed multiple overlapping and conflicting treatment orders for the right heel and right medial malleolus, including different instructions for cleansing, use of betadine, iodine, calcium alginate, Medihoney, and various dressings, with several orders remaining active simultaneously. During interview, the wound nurse responsible for pressure wound oversight acknowledged that some of these orders should have been deleted and was unable to identify which orders were correct for either the right heel or the right medial malleolus. Review of the treatment records revealed that ordered wound care was not completed on multiple specified dates for both the right heel and right medial malleolus wounds, despite the orders being in effect. On observation, the resident was found in bed on an alternating air mattress with the right foot elevated, and reported having several pressure wounds on the right foot caused by a boot previously worn at the facility. During a wound care observation, dressings dated three days prior were removed from the right heel, right superior heel, and right medial malleolus. The right heel wound was observed as unstageable with eschar; the right superior heel wound had a large amount of yellowish/greenish drainage with foul odor and was measured and classified as a stage 3 pressure ulcer with a pink granulating wound bed; and the right medial malleolus wound appeared unstageable with slough tissue and increased dimensions. The wound nurse performed cleansing and dressing changes using wound wash, betadine, calcium alginate, Medihoney, and bordered gauze, and used appropriate infection control technique. The resident reported pain rated between 7 and 9 out of 10 at the conclusion of the dressing changes.
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