Failure to Prevent and Appropriately Manage Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development of a facility-acquired pressure ulcer and did not follow its own policies and procedures regarding pressure ulcer care for one resident. Upon admission, the resident had no pressure ulcers and was assessed as low risk for developing them. However, a new stage II pressure ulcer developed on the resident's left heel during their stay. Documentation regarding the wound was inconsistent, with conflicting assessments about the stage and origin of the ulcer. The care plan was not updated with new interventions after the onset of the pressure ulcer, despite evidence of deterioration and changes in the wound's condition. Observations revealed that the resident's heels were resting on the footboard while sitting up in bed, which was not addressed in the care plan. The facility's policy required that preventative measures and care plan updates be implemented and documented for residents at risk or with pressure injuries, but these steps were not followed. Additionally, staff interviews indicated confusion about the resident's wound status and history, further highlighting lapses in assessment and care planning.