Failure to Implement MASD and Pressure Ulcer Prevention and Monitoring for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered wound and skin care interventions and to monitor and report skin changes for a resident at high risk for skin impairment with MASD and a history of a right heel pressure ulcer. The resident, who has Alzheimer’s disease, dementia, bowel and bladder incontinence, and an ADL self-care deficit, is nonverbal, confused, and requires total care. During observation, the resident was found on a low air loss mattress with a soiled brief, no sacral dressing, no heel dressings, and no heel boots, despite active physician orders and a care plan requiring MASD treatment to the sacrum/buttocks/perineum/thighs, foam dressings to the sacrum/buttocks, and heel dressings three times weekly with offloading devices. The sacrococcygeal area showed multiple clustered superficial open wounds/excoriations, redness over the sacral/buttocks area, and dark discoloration extending to the inner thigh, with no barrier or treatment cream residue present. Staff interviews revealed that the LPN on duty was unaware of the resident’s superficial open wounds and heel condition, stating she had not received any report from the prior nurse or CNA. The wound care coordinator also reported he was not aware of the new superficial open wounds on the sacral area or the dark scab on the right heel and stated he had not been notified of these skin changes by CNAs or floor nurses. The CNA assigned to the resident acknowledged she had not yet provided morning or incontinence care that day, although she had fed the resident, and the ADON stated CNAs are expected to check residents for incontinence every two hours and report any skin changes. The regular nurse for the resident, who had cared for her the previous day, also reported she was not aware of any sacral skin impairment and had not seen the sacral area, indicating that skin inspection and reporting were not occurring as required. Record review showed that the resident’s care plan and physician orders required keeping the skin clean and dry, monitoring skin during care and reporting changes, offloading heels with protective devices, and ongoing wound assessment for deterioration or improvement. The most recent wound report prior to the survey documented MASD to the sacrum/buttocks/perineum with 100% non-blanchable erythema and a healed right heel pressure ulcer with intact skin, but on the survey date the sacral area measured 4 cm x 4 cm as a clustered superficial open wound and the right heel showed dry scaly skin with scab formation and blanchable redness. Facility policies on skin condition assessment and pressure ulcer prevention required daily skin observation by CNAs during care, prompt reporting of changes to the charge nurse, several-times-daily skin inspection during hygiene and repositioning, timely linen changes when soiled, and use of positioning devices to reduce pressure and friction. These policy expectations were not followed, as evidenced by the resident being found soiled, without ordered dressings or barrier creams, and with unreported and unassessed skin breakdown.
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