Failure to Prevent and Properly Manage Pressure Ulcers
Penalty
Summary
The facility failed to identify and address the risk of pressure ulcer development, perform routine skin checks, and follow care plans to promote wound healing for two residents who developed facility-acquired heel wounds. In the first case, a resident admitted for therapy after fracture surgery, with diagnoses including diabetes mellitus with polyneuropathy, was assessed as at risk for pressure ulcers but had no comprehensive care plan addressing this risk. The clinical record lacked weekly skin observations for over a month, and a new pressure injury to the right heel was only documented after this period, by which time the wound had progressed and required advanced interventions, including a wound vac and surgical procedures. In the second case, another resident admitted for therapy after an accident was also assessed as at risk for pressure ulcers but did not have monitoring for skin breakdown prior to the development of a pressure injury. The resident developed a deep tissue injury to the left heel, and although a care plan was created after the ulcer appeared, there were multiple documented instances where prescribed wound treatments were not administered as ordered and not refused by the resident. This included several missed dressing changes over multiple months, as evidenced by gaps in the treatment administration record. Observations and interviews confirmed that wound care orders were not consistently followed, and dressings were not changed as scheduled. The facility's policy required regular skin inspections and adherence to physician orders for wound care, but these were not implemented as documented. The Director of Nursing acknowledged that staff should be following physician's orders as written, but the records and observations indicated otherwise.