Failure to Prevent and Manage Pressure Ulcers for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and wound care consistent with professional standards for one resident who was admitted with surgical wounds and Moisture Associated Skin Damage (MASD) and later discharged with a Stage 4 pressure ulcer. On admission, documentation noted breakdown on the proximal posterior left lower extremity related to a brace and MASD on the coccyx, but there were no measurements or detailed descriptions of these wounds. The resident was ordered to have a knee immobilizer applied twice daily, but the order did not specify what care was to be provided with the immobilizer, and nursing documentation only showed it was signed off on the MAR. A Braden Scale assessment identified the resident as high risk for pressure sores, and an order for barrier cream to the buttocks/peri-area with each incontinent episode was in place, but there were no signatures on the Treatment Administration Record to show the treatment was provided. Over the course of the stay, multiple new areas of skin breakdown developed, and documentation was inconsistent, incomplete, or missing. Care plans and nursing notes referenced skin impairment to the sacrum, left inner thigh, left great toe, and left posterior calf, but often lacked wound measurements, descriptions, or clear timelines of onset. A new wound to the left posterior calf was first noted by an aide after a shower, and subsequent notes described the area as black with surrounding pink skin, then later as open with yellow slough, moderate yellow drainage, and foul odor. Weekly skin assessments were delayed, with the first one dated months after admission, and when completed, they sometimes documented skin as pink, dry, warm, and intact at locations where other notes and physician documentation indicated the presence of Stage 4 ulcers. Physician notes later identified a Stage 4 ulcer of the left shin, a Stage 4 ulcer on the left hip, and a Stage 4 pressure ulcer of the right hip, in addition to the posterior left lower leg ulcer, but there were no corresponding wound treatment orders for the right or left hip on the MAR. The resident’s left hip surgical site, previously documented as a surgical wound, was later classified as a Stage 4 pressure ulcer without documentation of interventions to prevent further breakdown. There was also no documentation of when sacral skin breakdown developed. The resident had been admitted with a knee immobilizer and subsequently developed a Stage 4 pressure ulcer on the calf where the immobilizer was applied, and the record lacked documentation of interventions used to prevent skin breakdown. When surveyors requested additional information about preventive measures, the Administrator stated there was no documentation beyond what was in the medical record and was unable to provide further information.
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