Failure to Prevent Pressure Ulcers and Conduct Timely Skin Assessments
Penalty
Summary
The facility failed to implement meaningful interventions to prevent the development of a pressure ulcer for Resident #83 and ensure timely skin assessments for Resident #33. Resident #83, who was admitted with multiple diagnoses including a Stage 3 pressure ulcer, was observed to have a worsening condition of her pressure ulcer on the left buttock. Despite being reliant on staff for assistance with turning and repositioning, the facility did not replace her worn wheelchair cushion for over a month, which was a significant factor in the development and progression of her wound. The facility's care plan lacked proactive measures to prevent further skin breakdown, and interventions were only added after the wound had developed. Resident #33, who was admitted with conditions such as dementia and heart failure, had a suspected deep tissue injury on her right heel and ankle. The facility failed to conduct timely skin assessments, as there was a gap between assessments from March 14 to March 28, during which no skin assessment was completed. This oversight was acknowledged by the unit manager, who stated that skin assessments should have been conducted twice weekly in conjunction with shower days. The lack of timely skin assessments contributed to the failure to identify and address skin issues promptly. The facility's policy on skin risk assessment and treatment was not adequately followed, as evidenced by the lack of daily skin inspections and timely reporting of abnormal skin conditions. The deficiencies in both cases highlight a failure to adhere to established protocols for skin care and prevention, leading to the development and progression of pressure ulcers in the residents.