Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and heal pressure ulcers for a resident, as required by professional standards of practice. The resident, admitted with a fracture and muscle weakness, was dependent on staff for mobility and at risk for developing pressure ulcers. Despite this, the facility did not implement a turning and positioning program to prevent pressure ulcers, as confirmed by the absence of documented evidence in the resident's clinical record. The resident, who was at risk for skin breakdown due to immobility and bowel incontinence, developed deep tissue pressure injuries on the sacrum, left heel, and right heel, as well as a Stage 1 pressure injury on the right great toe while under the facility's care. The lack of a documented turning and positioning program was confirmed by the Unit Manager, indicating a failure to adhere to the necessary preventive measures for pressure ulcer development.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Treatment was provided to Residents R1 to address the pressure ulcer and prevent new ulcer from developing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for all Residents at risk for pressure ulcers to ensure proper treatment is being provided. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that treatment to prevent pressure ulcers is being provided and physician orders are followed. Audits will be conducted weekly for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.