Failure to Provide Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as observed during a recertification survey. Resident #389, who had severely impaired cognition and was dependent on staff for mobility, was admitted with venous and arterial ulcers. Despite the facility's policy on pressure ulcer prevention, the resident did not receive pressure-relieving devices or preventative measures to promote wound healing. Observations revealed that the resident lacked heel booties, offloading of heels, and a pressure-reducing mattress, both in bed and while seated in a wheelchair. The facility's documentation and staff interviews highlighted several lapses in care. The Braden Scale assessments indicated a moderate risk for pressure ulcers, yet there were no documented interventions for turning and repositioning the resident. The Electronic Medical Record lacked orders for pressure-relieving measures, and the Certified Nursing Assistant Accountability Record did not include tasks for turning and repositioning. Staff interviews revealed that the protocol for at-risk residents was not followed, and the necessary equipment and care plans were not implemented or documented. The Director of Nursing acknowledged the oversight and noted that new forms were being implemented, but the lack of documentation and preventative measures contributed to the deficiency.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? - For Resident # 389: - Pressure reduction mattress was provided on 2/12/2025 - Heel bootie for left foot was provided on 2/12/2025 - Turning and Positioning task was added to the CNA accountability on 2/26/2025 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - All residents at risk for developing pressure ulcers have the potential to be affected by this practice. - A facility wide audit is being conducted to ensure all residents at risk for pressure ulcers or with pressure ulcers receive necessary services (preventative measures) to prevent skin breakdown and to promote wound healing. - Any outstanding issues will be addressed immediately. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: - The Policy and Procedure “Prevention of Pressure Ulcers” was reviewed, and no revision needed. - All nursing staff is being re-educated on the “Prevention of Pressure Ulcers” policy, with emphasis on implementation and documentation of preventative interventions being done. - All unit managers are being in-serviced on review of new admissions/re-admissions for initiation of preventative skin care/interventions on person-centered care plan and for activation of tasks in EHR (PCC) for documentation of care. - The audit tool was developed for monitoring compliance with implementation of preventative skin care/interventions and tasks activation in EHR. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? - On a weekly basis for one quarter, ADNS or designee will audit newly admitted and readmitted residents’ charts to ensure compliance with preventative skin care is initiated and documentation of such; and residents’ with newly developed skin breakdown charts for appropriate interventions. Any outstanding issues will be addressed immediately and reported to DNS. - On a weekly basis for one quarter, MDS Director or designee, will audit 2-4 newly admitted/readmitted residents and residents with new skin breakdown to ensure skin care tasks activation in PCC and report the findings to DNS. - On a monthly basis DNS or designee will report findings to Administrator. - On a quarterly basis DNS or designee will report findings to QAPI Committee. - QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Assistant Director of Nursing.