Failure to Investigate and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to investigate the cause of newly developed pressure injuries and did not consistently implement preventive interventions for one resident. The resident, who was severely cognitively impaired and at high risk for pressure ulcer development due to multiple comorbidities including diabetes, incontinence, neuropathy, and peripheral vascular disease, had a care plan in place with interventions such as regular skin checks, repositioning, and use of pressure-relieving devices. Despite these interventions being documented in the care plan, there was no evidence that they were consistently carried out prior to the identification of new pressure injuries. A review of the resident's records showed that two unstageable pressure injuries developed on the left and right ischium, with wound assessments documenting progression in size and severity over several weeks. Physician orders for wound care were implemented after the wounds were identified, and the family requested offloading every two hours. However, there was no documentation to confirm that offloading or other preventive measures were consistently performed before the wounds appeared. Additionally, there was a lack of documentation of skin assessments between the last recorded shower and the discovery of the wounds. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that no investigation was conducted to determine the cause of the pressure injuries, nor was there a review to ensure that preventive interventions had been implemented as required. The facility's failure to investigate the cause and ensure consistent implementation of preventive measures led to the deficiency cited under the relevant nursing services regulation.