Failure to Implement Timely Pressure Ulcer Prevention Measures
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary treatment and services to promote healing and prevent worsening of pressure sores for a resident who was at high risk due to immobility, cognitive impairment, and incontinence. Upon admission, the resident was bedbound, had contractures, and was dependent on staff for all aspects of care. Initial assessments documented redness to the coccyx area, but there was a lack of specific documentation regarding whether the area was blanchable or non-blanchable, and no clear follow-up was conducted to clarify or monitor this area of concern. Despite the resident's high risk for pressure ulcers, there were no documented orders for repositioning, turning, or the use of positioning pillows or wedges prior to the development of a stage 2 pressure ulcer. The care plan and order summary did not reflect timely implementation of standard interventions such as regular repositioning or the use of offloading devices. Documentation of bed mobility and repositioning was inconsistent and did not meet the facility's protocol for at-risk residents, with records showing infrequent repositioning events. Interviews with staff, including the admitting nurse, wound care nurse, and DON, revealed that standard preventive measures were expected but not consistently implemented or documented. The wound care nurse and DON both acknowledged that interventions such as diligent repositioning and the use of pillows or wedges should have been in place immediately upon admission. The lack of timely and consistent preventive interventions led to the resident developing a stage 2 pressure ulcer, which later progressed to stage 3, indicating a failure to provide necessary care to prevent pressure injuries.