Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate care to prevent pressure ulcers for a resident identified as R19, who was at risk due to decreased mobility, bilateral above-knee amputation, and radiation therapy. R19 developed a facility-acquired stage 3 pressure injury (PI) that was not properly identified or staged by the facility. Instead, the facility considered it a chronic wound caused by friction and shearing from the use of a slide board transfer. Despite recognizing these risk factors, the facility continued to use the slide board and did not document any risk versus benefits discussion with R19 regarding its continued use. R19's medical history included prostate cancer, heart disease, venous insufficiency, and peripheral vascular disease, among others. The resident's care plan included the use of a Roho cushion and repositioning every two hours to prevent skin breakdown. However, there were delays in obtaining the Roho cushion, and R19 was observed using a rolled washcloth under his hip, which contributed to the PI. The facility did not provide alternative transfer methods to the slide board or adequately educate R19 on the risks associated with its use, leading to the deterioration and infection of the PI, which eventually required an EpiFix graft. The facility's failure to appropriately stage the PI and provide alternative transfer methods resulted in immediate jeopardy. The wound physician had identified the wound as a stage 3 pressure injury, but the facility did not classify it as such. The facility's inaction and lack of documentation regarding risk versus benefits discussions contributed to the development of two facility-acquired pressure injuries for R19, with the left ischial tuberosity deteriorating and becoming infected.
Removal Plan
- R19 was educated on Risks vs Benefits regarding use of the slide board and placing barrier on top of pressure relieving device which decreases effectiveness.
- Resident was consistently refusing interventions including, but not limited to, nutritional supplements, attending scheduled appointments regularly, participating in therapy and following recommendations of using Hoyer Lift instead of the slide board. This was also included in his Risks vs Benefits education.
- Nursing staff was educated regarding: Prevention of Pressure Injury, including: A. Pressure Points, Shearing, Friction and Proper Positioning. B. What to look for regarding what interventions are working and what are not.