Failure to Implement and Monitor Pressure Ulcer Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement and monitor pressure-relieving interventions and did not re-evaluate the effectiveness of pressure ulcer treatment for a resident at risk for pressure ulcers. The resident, who was cognitively impaired and dependent on staff for mobility, was admitted without pressure ulcers but developed an unstageable pressure ulcer to the coccyx shortly after admission. The care plan and physician orders specified the use of a low air loss mattress and regular repositioning, but these interventions were not consistently implemented, as evidenced by the resident being observed on a standard mattress after a room change. Despite ongoing wound assessments documenting worsening of the pressure ulcer, including progression from unstageable to stage 4 with increased size, tunneling, and drainage, the treatment plan was not revised in a timely manner. The wound continued to deteriorate over several weeks, with repeated documentation of heavy drainage, necrotic tissue, and infection. The wound care provider continued the same treatment orders for extended periods, even as the wound failed to improve and new complications developed. Staff interviews confirmed that the resident was not on the prescribed low air loss mattress due to a room change, and the wound care nurse acknowledged a lack of familiarity with negative pressure wound therapy, which may have been beneficial given the wound's condition. Facility leadership stated that they would expect a change in treatment after two weeks without progress, but this did not occur, contributing to the ongoing decline of the resident's pressure ulcer.