Failure to Provide Adequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide preventative care consistent with professional standards for two residents at risk for pressure injuries. Resident #98, who had a history of pressure injuries and was assessed as being at mild risk, was observed multiple times in a wheelchair with improper positioning and without adequate pressure relief. The resident's blue boots, intended to reduce pressure, were often not securely attached, and the resident was left in the same position for extended periods, leading to a pressure ulcer on the right heel. Despite having a catheter, the resident was not repositioned or provided with adequate pressure relief, and catheter care was not performed during an observed transfer. Resident #65, also assessed as being at mild risk for pressure injuries, was observed spending most of his time in a wheelchair without a pressure-reducing cushion, as required by his care plan. The resident was seated on a hoyer sling instead, which does not provide the necessary pressure relief. Staff interviews confirmed the absence of a pressure-reducing cushion, and the resident was observed in the same position for extended periods without repositioning, increasing the risk of skin breakdown. The report highlights the facility's failure to adhere to care plans and professional standards for pressure ulcer prevention, resulting in inadequate care for residents at risk of pressure injuries. The lack of proper positioning, pressure relief, and adherence to care plans for both residents demonstrates a significant deficiency in the facility's care practices, potentially leading to worsening of existing pressure injuries and the development of new ones.
Plan Of Correction
Element# 1 Braden assessment for resident #65, and #98 have been completed, and interventions implemented based on identified risk areas. Element# 2 Residents at risk for skin breakdown have the potential to be affected. Resident Braden assessment identifying residents at risk have been reviewed as well as appropriate interventions in place. Element# 3 Licensed Nurses and CNAs have been educated on Pressure ulcer prevention including repositioning and support surface implementation. Element# 4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s), will conduct weekly observation audits to ensure appropriate skin interventions are in place. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element# 5 The Administrator is responsible for sustained compliance.