Failure to Prevent and Manage Pressure Injury Due to Inadequate Care Planning and Communication
Penalty
Summary
The facility failed to provide adequate nursing care and services to prevent the development of a pressure injury for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including dementia, hyperlipidemia, and psychosis, was assessed as being at risk for pressure ulcers and required maximal assistance with mobility and personal care. Despite this, staff did not consistently follow a turning and repositioning schedule, and there was no individualized care plan addressing the resident's frequent refusal to be turned or repositioned. Observations revealed that staff encountered resistance from the resident during turning and repositioning, with the resident often holding onto siderails and appearing scared. Staff interviews confirmed that the resident regularly refused repositioning, and that this behavior was not effectively communicated or addressed through care planning. There was no documentation of a care plan to manage the resident's non-compliance, and staff did not consistently use positioning devices such as pillows to offload pressure from bony prominences. Additionally, staff did not always verbally report changes in the resident's skin condition, leading to delays in assessment and intervention. The lack of a coordinated approach and clear communication among staff contributed to the development of a deep tissue injury (DTI) on the resident's right malleolus. Facility policies required individualized interventions and care plan modifications in response to resident risk factors and non-compliance, but these were not implemented. The failure to develop and communicate a care plan for the resident's resistance to turning, inconsistent use of repositioning aids, and inadequate reporting of skin changes directly led to the deficiency.