Failure to Assess and Manage Pressure Injuries and Resident Refusals
Penalty
Summary
The facility failed to provide necessary care and services for pressure injuries (PIs) to one resident by not consistently assessing existing wounds, not documenting required wound characteristics and measurements, and not preventing the development of new PIs. The resident was admitted with medically complex conditions including a history of blood clots, dementia, impaired vision, significant cognitive loss, and behaviors of rejecting care. The admission MDS documented that the resident was at risk for PIs and had two unhealed, unstageable PIs suspected as deep tissue injuries (DTIs) on the right buttock and right heel. A Braden Scale assessment rated the resident at moderate risk for PIs due to being bedfast with very limited mobility and sensory perception, though later facility investigation documents described the resident as at extreme risk for impaired skin integrity. The resident was dependent on staff for eating, hygiene, toileting, bed mobility, transfers, bathing, and dressing. The facility’s skin integrity policy required licensed nurses to document skin impairments with measurements of size, color, odor, exudate, and pain on weekly wound evaluations, and to notify the medical provider, resident representative, and registered dietician, especially when wounds failed to improve or deteriorated. However, the admission skin/wound evaluation, created after admission and backdated, identified the two suspected DTIs but did not include measurements, wound assessment details, or pain documentation. There was no skin/wound evaluation completed on the documented admission date for either PI, and only the right heel PI was assessed on a subsequent date. A new unstageable PI on the resident’s right upper back was documented as identified several days after admission, but the skin/wound evaluation for this lesion was not completed until five days after it was found, and the section for registered dietician notification was left blank with no date entered. Observations later showed the upper back wound as an oblong open area and the right buttock wound as a large wound extending from the right buttock to the tailbone, with the resident stating that the buttocks hurt. Facility investigation of the newly acquired PI on the upper back identified the resident as at extreme risk for impaired skin integrity, citing profound immobility, deconditioning from sepsis, malnutrition, and inadequate hydration as root causes. Staff interviews indicated the resident refused to get out of bed and refused most oral intake, and documentation showed multiple refusals of meals, weekly weights, some medications, and one bath. Despite these refusals, progress notes over several weeks contained no indication that staff informed the provider of the resident’s refusals or explored the reasons for them. Staff also acknowledged that there should have been weekly wound documentation with measurements and characteristics, and could not explain the delay in assessing the new PI on the back or the discrepancy between the Braden assessment rating and the description of the resident as at extreme risk.
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