Failure to Prevent and Manage Pressure Ulcer Resulting in Harm
Penalty
Summary
The facility failed to consistently reposition, assess, and monitor skin integrity in a timely manner, and did not implement pressure offloading interventions to prevent the development of avoidable pressure ulcers for a resident identified as being at risk. The resident, who had a history of right hip fracture, spina bifida with impaired sensation, and required substantial assistance with mobility, was admitted without any pressure ulcers but was assessed as being at risk for their development. The care plan and Kardex indicated the need for staff assistance with turning and repositioning, as well as the use of pressure-relieving devices, but documentation and staff interviews revealed inconsistencies in the implementation and communication of these interventions. Despite being care planned for frequent repositioning and pressure relief, the resident developed an unstageable pressure ulcer on the sacrum, which was later diagnosed as a Stage 4 ulcer and became infected, requiring hospitalization. The resident and their family reported that after therapy services ended, staff did not assist with repositioning or provide reminders, and the resident, due to sensory loss, was unaware of the developing ulcer. Staff interviews indicated confusion regarding the level of assistance required for bed mobility and repositioning, and there was a lack of documentation regarding refusals of care or updates to the care plan in response to changes in the resident's condition or cooperation. Facility policy required individualized prevention and treatment plans, daily and weekly monitoring of pressure ulcers, and consistent implementation of interventions for residents at risk. However, the investigation found that the care plan was not consistently updated or followed, and there was insufficient documentation of care provided or resident refusals. The lack of timely and consistent interventions, monitoring, and communication among staff contributed to the development and worsening of the resident's pressure ulcer, resulting in significant harm.