Failure to Provide Pressure Ulcer Prevention and Skin Integrity Management
Penalty
Summary
The facility failed to provide appropriate care and services for the prevention and management of skin breakdown for two residents at risk for skin integrity issues. For one resident with a history of hemiplegia, hemiparesis, functional quadriplegia, and diabetes, the care plan required frequent incontinence checks and changes, as well as turning and repositioning every two hours due to severe risk for pressure injuries and the presence of a Stage 3 pressure ulcer and moisture-associated skin damage (MASD). Observations and staff interviews revealed that this resident was left lying on his back for over six hours without being repositioned or having incontinence care provided as required. Staff confirmed that the resident was not checked or changed according to the care plan and facility policy, and the necessary interventions were not implemented consistently throughout the observed period. Another resident, who was readmitted with morbid obesity, diabetes, and a history of falls, was found to have a palm-sized reddish/purplish discoloration/hematoma on the right trunk area upon readmission. Documentation and interviews indicated that the initial body check did not identify any skin issues, while a subsequent skin assessment noted multiple skin concerns, revealing inconsistencies in documentation. The care plan for this resident did not include any goals or interventions for the management or monitoring of the hematoma and skin discoloration. Staff interviews confirmed that no care plan or interventions were developed or implemented for this issue, and there was no ongoing assessment or reassessment of the affected area. Facility policies required individualized care plans, regular skin assessments, and timely interventions for residents at risk of skin breakdown. However, the facility did not follow these policies for either resident, as evidenced by the lack of timely incontinence care, repositioning, and the absence of care planning and monitoring for new or existing skin conditions. These failures were confirmed through direct observation, record review, and staff interviews.