Failure to Perform Weekly Skin Checks and Update Care Plan for Pressure Ulcer
Penalty
Summary
A resident with multiple sclerosis, quadriplegia, and muscle weakness developed an unstageable pressure ulcer to the left buttock while in the facility. The resident was identified as being at risk for pressure ulcers, requiring maximum assistance with bed mobility, and using a Roho cushion in the wheelchair and a pressure-reducing mattress. Despite provider orders for weekly skin checks and care plan interventions for pressure ulcer prevention, documentation revealed that weekly skin checks were not consistently performed, and the presence of an actual pressure ulcer was not promptly reflected in the care plan. Progress notes indicated that staff observed redness and later an open wound on the resident's left buttock, with the Roho cushion found to be flat and reportedly having been that way for some time. The cushion was reinflated only after the wound was discovered. Staff interviews revealed inconsistent knowledge and education regarding the proper maintenance and inflation of the Roho cushion, with some nursing assistants unaware of specific requirements and others relying on informal checks or verbal instructions. The care plan lacked individualized interventions such as specific repositioning frequency and did not include the presence of the actual pressure ulcer or integrated wound therapies in a timely manner. Further, the facility's documentation and assessments were incomplete, with missing sections in wound evaluation forms and a lack of detailed care plan updates following the development of the pressure ulcer. Staff interviews confirmed that repositioning and skin checks were not always performed or documented as required, and education materials regarding the Roho cushion were not provided. The facility's policy required individualized repositioning schedules and weekly skin inspections, but these were not consistently implemented for the resident.