Failure to Prevent and Monitor Pressure Injuries
Penalty
Summary
A deficiency occurred when staff failed to provide necessary care and interventions to prevent the development or recurrence of pressure injuries for a resident with a history of a Stage 4 pressure injury. The resident, who was cognitively intact and required partial to moderate assistance with mobility, was identified as being at risk for pressure injuries based on a Braden Scale score and care plan. The care plan required daily and weekly skin assessments, regular repositioning, and use of a low air loss mattress, but documentation and implementation of these interventions were lacking. Record reviews revealed that after an initial skin assessment in December, there were no further documented skin assessments, and the Braden Scale was not updated after December. The weekly nurse note only referenced the use of a low air loss mattress as an intervention, omitting other required measures such as regular repositioning and skin checks. Observations and staff interviews confirmed that the resident was left in the same position for extended periods, with one instance where the resident remained on her back from morning until afternoon without repositioning. Staff were unsure about the frequency of repositioning and failed to document skin assessments or interventions when redness was observed. The facility's policy required daily skin inspections, individualized repositioning schedules, and documentation of any changes in skin condition. However, these procedures were not followed, as evidenced by the lack of documentation, inconsistent repositioning, and failure to assess and report skin changes. These actions and omissions led to the resident developing significant skin redness and placed her at risk for further skin breakdown.