Failure to Prevent Pressure Injury Development
Penalty
Summary
The facility failed to prevent the development of a pressure injury for a resident identified as being at risk for skin breakdown. The resident, who had diagnoses including dementia, muscle wasting, and a history of a femoral neck fracture, was admitted with a care plan that included interventions such as floating heels while in bed, weekly skin assessments, and a pressure redistribution mattress. Despite these measures, a deep tissue injury (DTI) was discovered on the resident's right heel during morning care by a hospice aide. The injury was reported, and the facility's contracted wound healing specialists were notified. However, the facility did not revise the resident's care plan to include updated pressure-relieving interventions following the discovery of the injury. The resident's clinical records and facility documentation revealed a lack of consistent completion of preventative pressure injury tasks by staff. The Director of Nursing confirmed that the facility did not develop and implement necessary interventions to prevent the pressure injury after the resident's condition changed significantly and hospice services were initiated. This deficiency was identified as a failure to adhere to resident care policies and nursing services regulations as outlined in the Pennsylvania Code.
Plan Of Correction
Step 1 - Unable to retroactively fix resident 26, wound has already resolved. Step 2 - Review of residents deemed high risk for pressure ulcers to assure documentation in place or added to documentation for preventatives. DON or Designee. Step 3 - Education to nursing staff on completing and documenting preventative measures to prevention of pressure ulcers. Staff Educator or designee. Step 4 - Random audits of residents at high risk to assure preventative documentation is in place. Weekly times 4, Monthly times 2 - DON or designee. Step 5 - Results reported to QAPI Monthly times 2.