Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development and worsening of pressure ulcers for a resident with significant medical complexities, including cerebral atherosclerosis, diabetes with neuropathy, a history of stroke, and existing pressure ulcers. The resident was dependent on staff for all activities of daily living, including repositioning, and required specialized equipment such as a low air loss mattress and heel protectors. Despite care plans and policies indicating the need for frequent repositioning and use of pressure-relieving devices, the resident was observed multiple times without heel protectors and was not consistently repositioned as required. Documentation and interviews confirmed that repositioning occurred only 1-2 times per shift, rather than every two hours as specified in the care plan. Wound care documentation revealed inconsistent and incomplete assessment and measurement of the resident's pressure ulcers, with several instances where wounds were not measured or assessed weekly as required by facility policy. The resident developed new pressure ulcers, including a deep tissue injury to the right heel and a new open area near the left hip, which were not promptly identified or reported to nursing leadership. Observations showed that the resident was left in the same position for extended periods, and staff failed to implement or document non-pharmacological interventions for pressure ulcer prevention. Additionally, the resident was found sitting in a geri chair without a specialty cushion, only a pillow, further increasing the risk for pressure injury. Interviews with staff indicated a lack of communication and follow-through regarding new wounds, with one CNA stating she did not report a new pressure ulcer because a nurse was present. The hospice nurse was also unaware of the new wound, and wound assessments from hospice were not available in the facility's records. The facility's own skin management policy required weekly evaluation, measurement, and staging of pressure ulcers, but this was not consistently done. The cumulative effect of these failures resulted in the worsening of existing wounds and the development of new pressure ulcers for the resident.