Failure to Provide Timely Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with severe cognitive impairment, non-Alzheimer's dementia, and Multiple Sclerosis was identified as being at risk for pressure ulcers but initially had no such wounds. The care plan included interventions such as pressure-reducing devices for the bed and chair, a turning and repositioning program, and nutritional support. Despite these measures, the resident developed a dark purple, non-blanchable area on the right heel, later identified as a deep tissue pressure injury. Documentation shows that the resident experienced a change in condition, including lethargy, confusion, and increased care needs, but there was no evidence of repeated risk assessments or additional interventions at the time of this change, as recommended by professional guidelines. After the pressure injury was first documented, there was a significant delay in obtaining a wound care consult. Although the physician and family were involved in discussions about hospice care and wound management, the clinical record lacked documentation of timely attempts to secure a wound care consult or evaluation. Multiple progress notes indicated ongoing communication with the physician and family, but the facility did not document efforts to arrange for wound care services until much later, despite the wound increasing in size and changing in appearance. Additionally, the facility did not address the resident's footwear in relation to the pressure ulcer, even though the resident continued to wear shoes and slippers after the injury developed. Staff acknowledged the lag in wound care intervention and the lack of documentation regarding footwear recommendations. The facility's actions and omissions resulted in a failure to provide care consistent with professional standards to prevent the development of a pressure ulcer and to provide necessary treatment and services to promote healing once the ulcer was present.