Failure to Prevent and Manage Pressure Injury
Penalty
Summary
The facility failed to implement appropriate interventions to prevent and treat a pressure injury for a resident identified as R59, who was at moderate risk for pressure injuries. R59 was admitted with multiple diagnoses, including pulmonary embolism, diabetes, and vascular dementia, and required substantial assistance for mobility. Despite being assessed as high risk for pressure injuries in October 2024, the care plan did not include specific interventions to prevent pressure injuries on her lower extremities while sitting in a chair. This oversight led to the development of a deep tissue injury (DTI) on her right plantar foot, which was unstageable due to necrotic tissue. Observations and interviews revealed that the facility's staff, including the wound nurse, were not consistently implementing the prescribed interventions. The resident's pressure-relieving boots were not being used as ordered, and her feet were not properly offloaded, contributing to the development and persistence of the DTI. The wound nurse acknowledged that the injury had been present for months and was caused by the resident's sitting position. The care plan lacked documentation of interventions for the diagnosed pressure injury and did not include enhanced barrier precautions related to the wound. The facility's policy on pressure injury prevention and management was not followed, as evidenced by the lack of proper assessment and documentation of interventions. The physician confirmed that the facility should have had preventive measures in place, such as repositioning and the use of pressure-relieving devices, which were not documented or consistently implemented. The failure to adhere to the facility's policy and the absence of a comprehensive care plan for pressure injury prevention and management resulted in the development of the DTI for R59.