Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions as outlined in the care plans for three residents with dementia who are at risk for pressure ulcers. On March 31, 2025, three residents were observed sitting in wheelchairs without any pressure-relieving devices, such as cushions, during activities in the dining room. This observation was made twice, first at 11:08 AM and again at 12:15 PM. A Licensed Practical Nurse (LPN) acknowledged the absence of cushions and mentioned that sometimes staff send the cushions to the laundry, promising to ensure the residents receive the necessary cushions. The records for the three residents indicated that they were at risk for pressure ulcers, as documented in their respective care plans and Minimum Data Set (MDS) assessments. Each care plan specified the use of pressure-relieving cushions when the residents were seated in chairs. The facility's policy on pressure ulcer prevention also emphasized the importance of using pressure-relieving devices for at-risk residents. Despite these documented interventions, the facility did not adhere to the care plans, resulting in the deficiency noted by the surveyors.