Failure to Prevent and Properly Manage Facility-Acquired Pressure Ulcer With Osteomyelitis
Penalty
Summary
The deficiency involves the facility’s failure to implement and document appropriate pressure ulcer prevention and management for a resident identified as being at moderate risk for skin impairment. The facility’s own policies required comprehensive skin assessments, risk evaluations, pressure-relieving interventions, timely reassessment with any change in condition, and prompt notification of the nurse supervisor, medical provider, and wound nurse when new wounds or deterioration occurred. Despite Braden assessments indicating moderate risk, the resident’s care plan did not include pressure-relieving interventions, repositioning schedules, or documentation of pressure ulcer care. The resident was severely cognitively impaired and dependent on staff for all care, yet there was no initial assessment documented for when the coccyx pressure ulcer developed, and the wound nurse later stated she could not locate this initial assessment and had only documented that the pressure ulcer developed in July when she assumed her role. Over time, the resident developed a facility-acquired coccyx pressure ulcer that progressed from a stage 3 pressure injury with tunneling to an unstageable/stage 4 wound with osteomyelitis. Wound documentation on one date described a stage 3 full-thickness coccyx ulcer with a 2.2 cm tunnel and noted that the wound was acquired in-house with an unknown onset. A subsequent wound evaluation by a wound physician documented mechanical debridement of the coccyx wound, bone scraping to confirm osteomyelitis, copious bright red bleeding requiring direct pressure and calcium alginate with blood-stop granules, and instructions to keep the resident supine with direct pressure to the wound bed. Later nursing notes described bone particles visible in the wound bed and copious serosanguineous drainage. The resident ultimately required IV vancomycin for wound infection and debridement, and the wound nurse confirmed that the coccyx ulcer was a facility-acquired stage 3 pressure ulcer and that the resident grimaced or pulled away during dressing changes and debridements.
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