Failure to Implement Pressure Ulcer Prevention and Care Interventions
Penalty
Summary
A resident with significant cognitive impairment and total dependence on staff for activities of daily living was admitted with multiple complex medical conditions, including an anoxic brain injury, respiratory failure with tracheostomy, gastrostomy, and a sacral pressure ulcer. Upon admission, the resident was identified as being at risk for skin impairment, and a care plan was developed that included interventions such as turning and repositioning, use of heel boots, application of barrier cream, and use of a pressure redistribution mattress. Despite these planned interventions, repeated observations showed the resident consistently positioned on their back with their head and neck leaning to the left, left ear pressed against the pillow, and heels directly against the mattress. Documentation and interviews revealed that these interventions were not consistently implemented, as the resident was often found without both heel boots in place and was not regularly turned or repositioned as required. The resident developed new pressure ulcers during their stay, including a deep tissue injury on the right heel and an open area on the left ear, both of which were determined to be facility-acquired. The sacral pressure ulcer also worsened, increasing in size and depth, and was noted to have visible bowel movement in the wound image. There were no treatment orders or interventions in place for the new wounds on the right heel and left ear, and the care plan was not updated to address these new areas of skin breakdown. Family members reported that staff were not responsive to concerns about the resident's wounds and that the resident was rarely turned or repositioned during their visits. Staff interviews confirmed a lack of awareness and follow-through regarding the resident's wound care needs and the absence of required equipment, such as heel boots. Record review further indicated inconsistencies and omissions in documentation, including the lack of initial assessment and documentation of the right heel wound upon admission, despite prior hospital records indicating its presence. The DON and Administrator were unable to provide explanations for the lack of implementation of care plan interventions, the absence of timely wound assessments, and the failure to provide necessary treatments for new pressure ulcers. The facility's failure to operationalize its policies and procedures for pressure ulcer prevention and care, as well as the lack of comprehensive assessment and intervention, directly resulted in the development and worsening of pressure ulcers for this resident.
Plan Of Correction
Element 1: Resident 117 areas to right rear malleolus and left outer ear were assessed by the nurse on 5/9/25 with orders for treatments put in place to include heel boots, low air loss mattress, and care plan updated. Resident 117 was discharged on 05/13/2025. Element 2: A skin sweep of current residents, including current residents admitted since 4/25/25, was completed by the Director of Nursing/Designee by 5/14/25 for any new skin areas or skin areas missed on admission. Any new areas noted were assessed, had treatment orders entered, and care plans updated for interventions to prevent and promote healing of wounds. A one-time audit of current residents with wounds was completed to ensure the wounds have appropriate treatment orders and interventions to prevent and promote healing of wounds, including being turned and repositioned. This was completed by the Director of Nursing/Designee by 5/14/25. A one-time audit of residents' most recent Braden score was completed by the Director of Nursing/Designee by 5/14/25, and anyone with a Braden of 10 or below was placed on the yellow dot program for turning and repositioning. Element 3: The QAPI Committee has reviewed the Pressure Ulcer Prevention and Management policy and has deemed it to be appropriate by 5/14/25. The Director of Nursing and/or designee re-educated the Wound Care Nurse and the licensed nurses on the Pressure Ulcer Prevention and Management policy by 5/14/25, with emphasis on turning and repositioning, ensuring wound treatments are being completed, and appropriate interventions are in place to prevent and promote healing of wounds. Also, that all admissions need to have their skin assessed by 2 nurses. Nurse Aides were re-educated on the yellow dot program for turning and repositioning and checking residents' Kardex to ensure interventions are in place. This was completed by Staff Development Coordinator/Designee by 5/14/25. Wounds will be reviewed daily in the morning clinical Monday through Friday to ensure treatments are being completed and weekly in the standard of care meeting to ensure appropriate interventions are in place to prevent and promote wound healing. Admissions will be reviewed daily in the morning clinical Monday through Friday to ensure admission skin assessments are accurate and have been assessed by 2 nurses. Element 4: The Director of Nursing/designee will audit residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure interventions are in place and treatments are being completed to prevent and promote healing of wounds. The Director of Nursing/designee will audit residents with a Braden of 10 or less and residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure they are being turned and repositioned appropriately to prevent and promote healing of wounds. The Director of Nursing/designee will audit admission skin assessments weekly for 4 weeks, then monthly thereafter, to ensure all skin issues present on admission are documented appropriately and their skin has been assessed by 2 nurses. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible for maintaining compliance.