Failure to Implement and Document Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement and document physician-ordered preventive measures for a resident with a sacral pressure ulcer, resulting in the deterioration of the wound from stage 2 to stage 3. The resident, who has Parkinson's disease and muscle weakness, reported that dressing changes were not performed daily and that staff did not consistently turn or reposition him as ordered. Observations confirmed the resident was lying on his back without heel protectors, and the Treatment Administration Records (TARs) for March and April showed multiple unsigned shifts for required turning and repositioning. Additionally, discrepancies were found in the TARs, with records being modified after the fact to indicate compliance that was not originally documented. Clinical notes from the wound nurse practitioner documented a significant increase in the size of the sacral pressure ulcer over time, and staff interviews confirmed the importance of regular turning and repositioning to prevent pressure injuries. Despite physician orders for repositioning every two hours, continuous use of heel protectors, and a low air loss mattress, these interventions were not consistently established or documented. The resident's care plan included these interventions, but failure to follow and document them led to the worsening of the pressure ulcer.