Failure to Implement Pressure Relief Interventions for Surgical Wound
Penalty
Summary
A deficiency occurred when the facility failed to implement adequate and effective interventions to promote healing and prevent deterioration of a left below-the-knee surgical site with staples for a resident upon admission. The resident, who had a history of left below-knee amputation, hemiplegia affecting the left side, dementia, and other significant comorbidities, required staff assistance for bed mobility and was at risk for skin breakdown as indicated by a Braden Scale score of 17. Despite these risks, the care plan and physician orders did not initially include interventions to elevate or float the left stump, nor was there documentation of regular turning and repositioning or resident refusal of such care. Multiple observations over several days revealed the resident was consistently found lying on the left side with the left stump not floated or elevated, and no interventions in place to off-load pressure or promote healing of the surgical wound. Interviews with nursing staff and CNAs confirmed that the resident required assistance to turn in bed and did not refuse care, yet staff did not recall or document providing necessary interventions such as floating the stump or using pillows or wedges. The resident himself reported needing help to move in bed and did not refuse staff assistance when offered. The lack of appropriate interventions and documentation led to a decline and worsening of the surgical wound, as evidenced by wound assessments showing deterioration. The facility's own policy required a plan of care for prevention and/or treatment to include a turning schedule and off-loading, which was not implemented for this resident until after the wound had worsened.