Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide services to prevent the development of new pressure ulcers and did not implement appropriate skin care interventions for two residents with pressure ulcers. One resident, who was admitted with multiple diagnoses including spinal stenosis, recent spinal fusion, and diabetes, was dependent on staff for most activities of daily living and was at risk for pressure ulcers. Despite being identified as at risk, there was no evidence of preventive measures such as turning, repositioning, or frequent skin assessments upon admission. The resident developed new pressure wounds on the buttocks, which were not identified until several days after admission, and preventive interventions were only implemented after the wounds were discovered. Another resident, admitted with diabetes, acute kidney failure, cellulitis, and neuromuscular dysfunction of the bladder, also experienced inadequate wound care. This resident had a history of wounds on the lower extremities and developed additional pressure wounds on the buttocks and a new wound on the right big toe during their stay. The care plan for this resident was not updated with new interventions after the discovery of new wounds, and there was a delay in dressing changes and implementation of preventive devices, despite requests from the resident's family. The facility's own skin management policy requires identification and implementation of preventive measures for residents at risk of pressure injuries, as well as timely documentation and care planning. In both cases, the facility did not follow these protocols, resulting in the development and worsening of pressure ulcers, and a lack of timely and appropriate interventions to promote healing and prevent further skin breakdown.