Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary services to prevent and treat pressure ulcers for two residents. Resident R317, who was admitted with a Stage 3 pressure injury, did not have a care plan that included management of the injury or the use of a low air loss mattress, despite being totally dependent on staff for repositioning. The resident's physician orders also lacked preventative measures such as a low air loss mattress and assistance with turning and repositioning. The facility's policy on pressure injury prevention was not followed, as the care plan did not address the resident's specific needs for pressure ulcer management. Resident R51, diagnosed with dementia and depression, had a noted injury on the right big toe, which was not adequately followed up. Progress notes indicated a red/purple area on the toe, but there was no documentation of the progression, cause, or resolution of the injury. Interviews with staff confirmed the lack of follow-up and the failure to develop a pressure ulcer care plan. The facility did not implement preventative measures or ensure that residents received necessary services to prevent and treat pressure ulcers, as confirmed by the Director of Nursing.
Plan Of Correction
The care plans of the affected residents (R51 and R317) were updated to reflect preventive measures for a stage III wound and a right great toe injury. RNs and LPNs will be educated by the Director of Nursing, In-Service Director, or designee on the importance of including in the clinical record how an injury occurred, its progression, treatment, and healing. The facility will audit the care plans of five random residents with wounds and skin issues weekly for three weeks and then bi-weekly for three weeks to ensure that documentation in the clinical record is complete and comprehensive (how the injury occurred, its progression, treatment, and healing). Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee, and the need for additional monitoring will be determined by the committee.