Failure to Implement and Document Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure that a resident at risk for pressure injuries received the necessary treatment and services to prevent the development of a new pressure ulcer. Despite having physician orders in place for a pressure redistribution mattress and heel protectors, these interventions were not consistently implemented or documented. The resident, who had multiple risk factors including dementia, diabetes, muscle wasting, and was dependent on staff for activities of daily living, was identified as being at risk for pressure ulcers and had a history of unhealed pressure injuries. Documentation revealed that the resident did not have a pressure redistribution mattress in use as ordered, and heel protectors were not implemented until after a new right heel wound was identified. There was a gap in documentation and implementation of these interventions, as the medication and treatment administration records did not show use of the mattress or heel protectors prior to the development of the wound. The wound was first noted as a non-blanchable area on the right heel, and subsequent wound evaluations did not consistently involve assessment by a physician, nurse practitioner, or wound care specialist, nor did they identify the source of pressure or factors contributing to improvement. Staff interviews confirmed that the resident's risk for pressure injuries increased as her condition declined, yet interventions were not adjusted accordingly. The facility's wound nurse acknowledged that the root cause of the pressure injury was not adequately identified and that the resident's shoes and leg rests may have contributed to the development of the heel wound. The facility also failed to ensure ongoing and thorough assessment of the wound, as the condition of the right heel was not evaluated after a certain point, and the nurse practitioner did not assess the wound until after the resident returned from a hospital stay.