Failure to Prevent Pressure Ulcers
Penalty
Summary
Whitestone Care Center was found to be non-compliant with federal and state regulations regarding the prevention and treatment of pressure ulcers. The facility failed to develop and implement adequate care and services to prevent the development of pressure ulcers for a resident. This resident, who was admitted with severe cognitive impairment and multiple health issues including Fournier gangrene, Type 2 diabetes, and cerebral infarction, was identified as being at risk for pressure ulcers. Despite this, the facility did not take sufficient preventative measures. The resident's care plan included interventions such as providing a pressure-reducing mattress and wheelchair cushion, incontinence care, and repositioning every two hours. However, there was no documented evidence that these measures were consistently implemented. Specifically, the facility did not document turning and repositioning the resident every two hours or elevating the resident's heels off the bed, which are critical actions to prevent pressure ulcer development. A new unstageable pressure ulcer was discovered on the resident's left heel, which was not identified in the facility's weekly skin assessment but was noted by an outside wound consultant. The facility's failure to document and implement preventative measures, such as pressure relief for the resident's heels, contributed to the development of this pressure ulcer. The Nursing Home Administrator confirmed the lack of documented evidence for the timely and consistent implementation of these preventative measures.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Step One Resident #1 no longer resides at the community. Resident #1 wound consultant recommendations implemented on November 14, 2024. Step Two To identify like residents that have the potential to be affected, the DON/designee conducted a whole house review of physician/nursing ordered pressure reduction interventions and validated proper placement, cross-referencing the device list. The DON/designee will conduct an in-house review of wound consultant reports to ensure timely follow-up of recommendations. Step Three To prevent this from happening again, the DON/designee will educate the licensed nursing staff and CNA staff on the utilization and review of the device list ordered interventions and the importance of ensuring they are in place. To prevent this from happening again, the DON/designee will educate the licensed nursing staff on timely follow-up of wound care consultant recommendations. To prevent this from happening again, the DON/designee will educate the Department Head staff on the use of the device list which lists ordered interventions and ensuring during concierge rounds the importance of ensuring they are in place. Step Four To monitor and maintain ongoing compliance, the DON/designee will conduct an audit of 5 residents per week for 4 weeks, then monthly for 2 months to ensure all ordered interventions are in place. The DON/designee will conduct an audit of 5 residents with orders for wound consults per week, then monthly for 2 months to ensure timely follow-up to recommendations. Results of audits will be submitted to the QAPI committee for further review and recommendation.