Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
A resident with a history of unstageable pressure ulcers to the heels was not provided with adequate care and services to prevent the development and worsening of pressure injuries. The resident was observed multiple times with his feet pressed against the footboard of a bed that was too short, resulting in wounds on both heels and toes. The resident reported pain and that his feet were not being cleaned as needed, and observations confirmed the presence of open, bleeding, and scabbed wounds on his heels and toes, as well as soiled pressure-relieving boots and bedding. Nursing and agency staff were not consistently aware of all the resident's wounds, with some staff unaware of wounds on the toes and wound care orders not covering all affected areas. Wound assessments and documentation showed a lack of timely identification and treatment of new or worsening wounds, including a newly developed unstageable pressure injury to the right heel and scabbed, bleeding toes. The resident's care plan included the use of foam heel suspension boots and offloading, but these interventions were not consistently or effectively implemented, as evidenced by the resident's ongoing contact with the footboard and the condition of his feet. Record review indicated that the resident had a history of pressure injuries to both heels and toes, with recommendations for offloading and repositioning. Despite these recommendations, the resident continued to experience preventable skin breakdown due to inadequate offloading, insufficient wound care, and lack of cleanliness. The failure to provide necessary care and services consistent with professional standards resulted in the development of new pressure injuries and the potential for further harm.