Failure to Provide and Document Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement and document appropriate pressure ulcer prevention and care measures for two residents at risk for pressure injuries. For one resident with a history of decreased mobility, diabetes, and recent hospitalization, staff did not ensure consistent offloading of the heels or develop a documented repositioning plan, despite the presence of a left heel pressure ulcer. The resident's care plan directed side-to-side turning and repositioning in bed and chair, but the electronic health record (EHR) lacked a turn and repositioning program, and staff interviews revealed confusion about documentation requirements. Additionally, an ordered offloading bootie was not provided due to a missed order, and the resident's left heel was observed to be in direct contact with the mattress during inspection. Another resident with severe cognitive impairment and total dependence for activities of daily living was also at risk for pressure ulcers. The care plan specified the use of a low air loss mattress and pressure-relieving cushions, but the resident was observed with a regular mattress and no air mattress order was found in the physician's orders. The EHR and care plan lacked a documented turn and repositioning program, and staff interviews indicated that the resident had never had an air mattress as required. The resident developed open areas on the buttocks and lower shin, with inconsistent documentation and communication regarding wound assessments and interventions. Facility policy required skin assessments, Braden Scale evaluations, timely wound nurse assessments, and individualized care plans with specific wound healing interventions and repositioning schedules. However, these standards were not consistently followed for the residents reviewed, resulting in missed interventions, lack of documentation, and failure to provide required equipment and care as outlined in the residents' care plans and physician orders.