Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
Nursing staff failed to implement the care plan interventions for a resident who was admitted with intact skin and identified as being at moderate risk for pressure ulcer (PU) development. The resident's care plan included applying barrier cream and performing daily skin checks to prevent skin breakdown, but these interventions were not carried out. Documentation showed that the resident was bedfast, had limited mobility, and required total assistance with personal care, placing them at increased risk for PU. Despite these risk factors, there was no evidence that barrier cream was applied or that daily skin assessments were documented. As a result of these omissions, the resident developed a stage 2 pressure ulcer on the sacral area, which was identified when the resident was transferred to the hospital. Interviews with the treatment nurse and DON confirmed that the prescribed interventions were not followed, and the facility's policy required daily skin inspections and use of barrier products for residents at risk. The lack of adherence to the care plan and facility policy directly led to the development of the pressure ulcer.