Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to consistently provide care and services to prevent the development of pressure ulcers and to promote healing of existing wounds for a resident. The resident, who was admitted with a history of dementia and peripheral insufficiency, was identified as being at risk for skin breakdown due to incontinence and the need for extensive assistance with activities of daily living. Despite this, there was no documented evidence that incontinence care was consistently provided with each episode or that a barrier cream was applied as required by the resident's needs and consistent with professional standards of practice. On April 11, 2025, a nurse noted the presence of an open area in the intergluteal cleft of the resident, which was moist with light yellow slough and no observable drainage. The resident was incontinent of bowel and bladder and occasionally refused incontinence care, repositioning, and showers. Despite the resident's condition, the facility did not timely implement interventions such as the use of a low air loss mattress, which was not placed on the resident's bed until April 13, 2025. Further observations revealed additional pressure ulcers on the resident's right buttock, which were not present during a skin assessment conducted the previous day. The facility failed to conduct a thorough investigation into the development of these pressure areas to identify possible causes and corresponding interventions. The Director of Nursing confirmed that an investigation was not completed, and interventions were not timely implemented to prevent the development of pressure areas for this resident.