Failure to Prevent and Timely Identify Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services, including individualized interventions, to prevent the development and identification of a Stage 3 pressure ulcer on a resident’s buttock. The facility’s skin policy required a full-body skin assessment within 6 hours of admission, weekly skin assessments, quarterly Braden Scale risk assessments, and use of skin sheets by direct care staff to report abnormalities. For this resident, admitted with diagnoses including CHF, ESRD, heart failure, anemia, and depression, there was no Braden Scale completed upon admission and no documented weekly skin assessments after the initial admission assessment. The admission note documented normal skin color and temperature with no open areas but did note superficial skin loss on the buttocks, and the care plan identified risk for alteration in skin with interventions such as barrier cream and turning/positioning every two to three hours, yet there was no documentation that barrier cream was applied. In the days following admission, the resident was repeatedly observed sitting and sleeping in a recliner without a pressure-relieving cushion. The resident reported sitting in the recliner all the time, sleeping there because of fear of rolling out of bed, and primarily lying on his/her back. The resident stated that his/her bottom was sore and that staff had applied “some type of cream,” but also reported that no nurse had looked at the area. Observations on consecutive evenings and early mornings showed the resident in the recliner on his/her back, still without a pressure-relief cushion, despite the facility policy that staff should encourage bed use and provide a cushion for the recliner as needed. The pressure ulcer was identified only when a CNA responded to the resident’s call light for toileting and the resident complained of pain in the bottom while sitting on the toilet. The CNA observed an open area on the inner left buttock about the size of a quarter with bloody drainage and white tissue in the center surrounded by red to pink tissue, and reported not having seen it before. An LPN then assessed the area and described the larger open area as deep with white tissue and some drainage, with the appearance of a Stage 3 pressure ulcer, and also noted a superficial open area on the left buttock. The LPN stated he/she had not been notified of these open areas prior to that day. Review of the medical record showed no completed skin assessments after admission and no skin sheets per facility policy, and interviews with leadership confirmed expectations that Braden assessments, weekly skin checks, and prompt identification and reporting of skin issues should have occurred but did not in this case.
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