Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure injuries for a resident who was dependent on staff for repositioning and had a history of pressure injuries. The resident was admitted with multiple risk factors, including aftercare following joint replacement, type II diabetes, incontinence, and existing pressure injuries. The care plan required staff to reposition the resident every two hours and to use pressure-relieving devices, but documentation and observations showed these interventions were not consistently implemented. On multiple occasions, the resident was observed lying in bed with her buttock and heels in direct contact with the mattress, despite orders to float the heels and offload pressure areas. The resident and her family member reported that staff did not attempt to reposition her or alleviate pressure, and the family member brought in a wedge to help offload the resident's heel due to lack of staff intervention. Interviews with staff revealed a lack of awareness or mention of repositioning as part of routine care for dependent residents. As a result of these failures, the resident developed a stage II pressure injury to the right heel and a stage III pressure injury to the right buttock, neither of which were present on admission. Facility policy required regular repositioning and use of support devices to prevent pressure injuries, but these protocols were not followed, as evidenced by staff interviews, resident and family reports, and direct observations.