Failure to Follow Wound Orders and Identify All Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services to prevent pressure injuries from developing and to promote healing of existing wounds for one resident. The facility had a Pressure Injury Prevention and Managing Skin Integrity policy requiring Braden Scale risk assessments, comprehensive skin checks on admission and weekly, identification and care planning of skin breakdown, and collaboration with the IDT and providers for abnormal skin findings. The policy also required weekly wound rounds, provider notification of wound decline, and adherence to ordered interventions. Despite these requirements, the facility did not consistently follow its own policy or ensure that wound treatments were based on provider orders. The resident was admitted with multiple significant conditions, including complete paraplegia, type 2 diabetes, morbid obesity, neurogenic bowel and bladder, and a history of sacral pressure injuries. On admission, an RN documented a stage 2 coccyx pressure injury and coccyx bruising, and later a left gluteal MASD, with subsequent development of an unstageable coccyx deep tissue injury. Wound assessments documented a large sacral/coccyx area with deep purple discoloration and scattered open areas, and an APNP ordered cleansing with soap and water, application of chamosyn cream twice daily, aggressive offloading, and specifically indicated not to cover the wound with a dressing. Facility orders reflected these directions, including repositioning every two hours and weekly skin checks. However, the facility’s documentation did not show any wound orders on the hospital discharge summary at admission, and the facility relied on its own wound team and internal assessments to manage the coccyx wound. An LPN reported that, on a weekend, after noticing what appeared to be an open area on the resident’s buttocks, the LPN applied 4 x 4 foam border adhesive dressings and barrier cream multiple times due to the resident’s frequent loose stools causing dressings to come off. The LPN stated they sent a message to the provider when the open area was noticed but could not locate any provider order in the medical record authorizing the use of foam border dressings during the period they were applied. The DON later stated that staff should not apply foam border dressings without an order and that the provider should have been informed as soon as the wound was identified. Additionally, a separate pressure injury on the resident’s penile/scrotal area was not identified by facility staff during the admission head-to-toe skin assessment and was instead discovered later at the hospital, where documentation indicated the resident and family were not aware of this wound until that hospitalization. The DON confirmed that admission skin assessments should include viewing all skin areas, and the RN who performed the admission assessment stated that if a penile pressure injury had been seen, it would have been documented, indicating that this wound was not identified by the facility prior to the hospital finding it.
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