Failure to Prevent and Manage Pressure Ulcers and Inadequate Use of Pressure-Relieving Devices
Penalty
Summary
The facility failed to prevent and implement adequate preventive measures for pressure ulcers in two residents, resulting in the development and progression of pressure injuries. One resident, who was dependent on staff for activities of daily living and had multiple comorbidities, reported pain and the presence of open areas on her lower buttocks. Despite her complaints and visible wounds, there was no timely assessment, documentation, or physician orders regarding the pressure ulcers. The wound nurse only became aware of the wounds after the resident reported pain, and there was a delay in initiating appropriate interventions, such as the use of an air mattress. The resident stated she was not asked to get up for the air mattress to be installed, contrary to staff claims that she refused, and the air mattress was not put in place in a timely manner despite being marked as a critical request. Another resident developed a facility-acquired Stage IV pressure ulcer. Initial skin assessments documented intact skin, but within days, the resident developed a macerated area that progressed to an open wound with slough, and eventually to a Stage IV ulcer. The resident was incontinent and sometimes refused care, but there was a lack of consistent documentation and timely escalation of care. During wound care observations, improper infection control practices were noted, including cross-contamination during dressing changes and failure to perform hand hygiene between cleaning stool and applying wound dressings. The air mattress in use for this resident was not set or managed according to any documented protocol, and staff demonstrated a lack of understanding regarding the appropriate settings and functions of the mattress. Care plans and in-room care guides for both residents lacked specific instructions regarding air mattress settings and pressure ulcer prevention measures. Staff interviews revealed confusion and lack of knowledge about air mattress operation, and there was no facility policy or procedure for their use. The absence of clear protocols, timely interventions, and proper documentation contributed to the development and worsening of pressure ulcers in both residents.