Failure to Implement Comprehensive Pressure Ulcer Prevention and Proper Wound Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for a resident who was at high risk for pressure ulcers due to multiple factors, including impaired cognition, dependence on staff for most activities of daily living, and limited mobility. The resident was admitted with several diagnoses, including acute kidney failure, hypertension, osteoarthritis, and muscle wasting with atrophy. The care plan identified the resident as being at risk for impaired skin integrity and included interventions such as regular skin assessments, turning and repositioning every two hours, incontinence care, and the use of pressure-relieving devices. However, documentation revealed that these interventions were not effectively implemented or monitored, as evidenced by the development of an in-house acquired unstageable pressure ulcer to the right gluteal fold. Nursing documentation and wound assessments were inconsistent and incomplete. A new area was noted on the resident's right gluteal fold, but there was no staging, description, or measurement documented at the time of discovery. The wound was later assessed as unstageable with 90% slough, and it was incorrectly documented as present on admission. Interviews with nursing staff revealed a lack of communication regarding the resident's care needs, including an instance where the resident refused to turn, which was not communicated or documented in the care plan. The Minimum Data Set (MDS) assessment was also marked incorrectly, indicating that turning and transfers were not attempted due to a medical condition, despite there being no such condition preventing these interventions. Infection control practices during wound care were not followed according to facility policy. During an observed dressing change, the wound nurse failed to perform hand hygiene between handling two separate wounds, used the same gloved hands and supplies for both wounds, and did not change gloves or wash hands after removing old dressings. This created a potential for cross-contamination, especially since one of the wounds was known to be infected. The facility's policies on pressure injury prevention and wound care were not adequately followed, and there was no specific guidance for managing multiple wounds during dressing changes.