Failure to Update Care Plan and Prevent Pressure Ulcers
Penalty
Summary
A resident who was identified as being at risk for pressure ulcers, as indicated by their Minimum Data Set (MDS) assessment and Braden scale, developed deep tissue injuries (DTIs) on both heels after experiencing a decline in health and spending increased time in bed. The resident's care plan, which noted their risk for skin breakdown due to decreased mobility and incontinence, did not include updated interventions such as floating heels, despite the resident's change in condition and increased immobility. Progress notes and staff interviews confirmed that no new preventive measures were implemented when the resident's health status declined. The wound treatment nurse acknowledged that the care plan should have been updated to include heel-floating interventions and that the pressure injuries were avoidable. Observations revealed the presence of an unstageable pressure injury on the left heel and skin discoloration on the right heel, with the left heel requiring a dressing. The lack of timely intervention and care plan updates led to the development of these pressure injuries.