Failure to Develop and Implement Comprehensive Pressure Ulcer Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan with specific interventions to prevent pressure ulcers for one resident. The resident had multiple diagnoses, including schizophrenia, dementia, bipolar disorder, hypertension, acquired absence of toes, and peripheral vascular disease, and was assessed as having severely impaired cognition and high risk for pressure ulcers. Despite these risk factors, the care plan did not include a care area or interventions for skin breakdown, and there was no turning or repositioning program in place. The resident required substantial assistance with activities of daily living and was dependent on staff for bed mobility and personal care. Clinical documentation showed that the resident developed a fluid-filled blister on the right heel, which progressed to an open, stage 3 pressure ulcer. Physician orders and wound clinic assessments directed the use of a low air-loss mattress, heel protectors, and specific wound care treatments. However, observations revealed that the resident was not consistently wearing protective boots while in bed, and staff were not always aware of or able to articulate the interventions in place to prevent or treat the pressure ulcer. Additionally, dietary staff were unaware of the resident's skin breakdown and no additional dietary interventions or supplements for wound healing were provided. Interviews with nursing and dietary staff confirmed gaps in communication and implementation of care interventions. The administrative nurse acknowledged the absence of a pressure ulcer care plan, and staff education on the importance of offloading and pressure relief was documented but not consistently followed. The facility's policy required the development of an individualized, comprehensive care plan within seven days of assessment, but this was not completed for the resident in question.