Failure to Prevent and Manage Pressure Ulcer in High-Risk Resident
Penalty
Summary
A resident with multiple comorbidities, including schizophrenia, dementia, bipolar disorder, hypertension, acquired absence of toes, and peripheral vascular disease, was identified as being at high risk for pressure ulcers. Despite this, the resident did not have pressure-relieving devices for her bed or chair, was not on a turning or repositioning program, and her care plan lacked interventions to prevent skin breakdown. The Braden Scale assessments consistently documented a very high risk for developing pressure ulcers, and the Pressure Ulcer Care Area Assessment directed staff to observe and report any skin changes, but these preventative measures were not implemented. The resident developed a Stage 3 pressure ulcer on her right heel. Documentation showed that staff observed a fluid-filled blister, and a low-air-loss mattress was ordered after the ulcer developed. Physician orders were given for wound care and the use of heel protectors, but there was evidence that the resident was not consistently wearing the protective boots as required. Observations confirmed that the resident was found in bed and in the living room without the protective boots on, and staff interviews revealed a lack of awareness regarding the interventions in place before and after the ulcer developed. Additionally, after the development of the pressure ulcer, there was no documentation that the Registered Dietitian was notified or involved for nutritional recommendations to promote wound healing. The clinical record lacked evidence of a dietitian evaluation or recommendations during the period following the onset of the pressure ulcer. Dietary staff were unaware of the resident's skin breakdown, and the resident was not receiving any additional protein or supplements for wound healing. The facility's policy required routine preventative care, including proper positioning, use of pressure relief devices, and maintaining adequate nutrition, but these measures were not consistently implemented for this resident.