Failure to Prevent and Manage Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to consistently provide care and services in accordance with professional standards to prevent the development of pressure ulcers for one resident. The resident, who had multiple risk factors including dementia, decreased mobility, incontinence, and a history of falls, was identified as being at risk for impaired skin integrity. The care plan included interventions such as regular skin assessments, keeping the skin clean and dry, applying protective creams, and using a mechanical lift for transfers. Despite these interventions, the resident developed multiple open and discolored areas on the buttocks and sacrum, which were identified by staff during routine care. Clinical documentation and staff witness statements revealed that the resident was resistive to repositioning and required significant assistance with activities of daily living. Initial assessment found a new open area on the left inner gluteal fold, followed by the discovery of additional open and non-blanchable areas on the buttocks and sacrum. The wounds progressed to deep tissue injuries and unstageable pressure injuries, with the presence of slough and eschar. The facility's investigative reports and nursing notes documented the progression of these wounds and the resident's combative behavior during care, which further complicated wound management. Although the care plan addressed the resident's risk factors, the facility did not implement timely and adequate preventive measures to prevent the development of pressure ulcers. The documentation also indicated that detailed wound descriptions and measurements were not provided to the resident's wife prior to discharge. Interviews with the DON and NHA confirmed the failure to prevent the development of pressure ulcers in this resident, as required by professional standards and regulatory requirements.