Failure to Prevent and Manage Pressure Ulcer Due to Inconsistent Pressure Relief and Documentation
Penalty
Summary
A deficiency was identified when a resident with multiple risk factors, including diabetes mellitus, muscle weakness, muscle wasting, abnormal posture, and dementia, developed a stage 3 pressure ulcer on the left heel. The resident was largely immobile, unable to move his neck upright, and could only move his right arm and hand. During care observations, staff elevated the resident's left foot on a pillow but did not use any other pressure-relieving device for the foot, despite a pressure-relieving boot being available at the bedside. The resident's specialty air mattress was found set on 'firm,' and staff were unaware of the correct settings for the mattress or how to adjust it appropriately. The facility did not provide the mattress manual or clarify the correct settings when requested by the surveyor. The DON confirmed the pressure ulcer was facility-acquired and could not identify the cause. There was no documentation or process in place to determine the cause of the pressure ulcer, and the facility's policy did not address this. The care plan noted the resident sometimes refused care, but there was no documentation of refusals related to pressure relief prior to the ulcer's development, nor any evidence of communication with the resident's guardian or brother regarding refusals. The care plan included interventions such as using an alternating pressure mattress and a pressure-relieving boot, but these were not consistently implemented or documented as refused. Additionally, staff did not have clear expectations or documentation practices for reapproaching the resident after refusals or for involving the guardian or family members to assist with compliance. The lack of consistent use of pressure-relieving devices, unclear mattress settings, and insufficient documentation and communication regarding care refusals contributed to the resident developing a stage 3 pressure ulcer.
Plan Of Correction
ELEMENT #1: ACTION TAKEN: Resident #26 will have a review of positioning devices, and the alternating pressure mattress will be set per manufacturer guidelines. The resident person-centered plan of care will be reviewed to ensure interventions are in place and utilized to promote wound healing and prevent further pressure injury development. Updates will be made to the person-centered plan of care as needed based on this assessment. ELEMENT #2: IDENTIFICATION OF OTHER RESIDENTS: Residents residing at Lake Woods have the potential to be affected. The resident's person-centered plan of care will be reviewed to validate interventions are in place and utilized to promote wound healing and prevent pressure injury development. Updates will be made to the person-centered plan of care as needed based on this assessment. ELEMENT #3: MEASURES TAKEN: Lake Woods will provide reeducation to licensed nursing staff and certified nursing assistants by 5/26/2025 prior to the next day worked in the case of the leave of absence, vacationing employee. The educational agenda will include application of person-centered interventions, with examples provided of various interventions for utilization to prevent worsening or the development of pressure injuries. The education will include the location of the resident's preference of settings for their alternating pressure mattress to ensure it is followed. ELEMENT #4: MONITORING: The Director of Health Care Services and/or designee will conduct rounds 3-5 times per week for 4 weeks on varying shifts to evaluate the education provided and inspect for the implementation of care planned interventions, including a review of the alternating pressure mattress settings, to prevent worsening or the development of pressure injuries. The Director of Health Care Services will compile a report of this audit for review and recommendation by the Quality Assurance Performance Improvement Committee monthly times one (1) month and periodically thereafter. The Director of Health Care Services will assume responsibility for sustained compliance.