Failure to Perform Skin Assessments and Timely Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for one resident at risk for skin breakdown. The resident had diagnoses including dementia without behaviors, right hip pain, depression, and a documented Stage 3 pressure ulcer to the right hip. A facility assessment showed the resident had moderate cognitive impairment, required partial to moderate assistance with rolling, and was at risk of developing pressure ulcers. The care plan identified increased risk for pressure ulcers related to decreased mobility, generalized muscle weakness, and need for staff assistance with transfers, and included interventions such as assisting with turning and repositioning and performing skin checks each shift. Despite these identified risks and care plan directives, the facility did not perform or document weekly skin assessments for the resident, and there were no physician orders for weekly skin assessments during the relevant period. On a documented date, staff identified what appeared to be an unstageable pressure injury to the right ischial protuberance, measuring 2 x 2 cm, with a completely dry wound bed and indurated edges. A bordered foam dressing was applied and staff indicated they would contact the primary provider for treatment orders and endorsed this to the next shift. However, there were no treatment orders or documentation of any treatments for the pressure wound for several days following this initial identification. Subsequent wound physician notes documented that the wound was a Stage 3 pressure wound of the right hip, full thickness for more than one day, with light serous exudate, and later described necrotic tissue, slough, and granulation tissue. A surgical excisional debridement was performed to remove necrotic tissue and establish viable margins, after which the wound was staged as a Stage 4 pressure wound of the right hip. Interviews with nursing staff and the DON revealed that skin assessments were reportedly done weekly or on shower days, but that if no skin alterations were reported by aides, nurses did not complete skin assessments, and there were no shower sheets. The wound care physician stated that a full-thickness wound of this type would not have developed within a few days and emphasized that facility staff are responsible for completing skin assessments on all residents to identify even small wound alterations. The DON acknowledged the absence of documented weekly skin assessments for this resident and that the wound being found at a late stage was an issue.
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