Failure to Provide Pressure Ulcer Prevention and Wound Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure injuries for a resident admitted with a Stage 3 pressure injury on the sacrum. Despite being identified as high risk for pressure injury on Braden Scale assessments, the resident was not provided with a low air loss mattress as required by facility policy and physician order. Multiple observations confirmed the resident was resting and sleeping in bed without the appropriate pressure-relieving mattress, and staff interviews revealed confusion and lack of follow-up regarding the mattress order, with insurance issues cited as a reason for the delay. The case manager was unaware of the need for the mattress, and the ADON acknowledged the resident should have received one within a month of admission. Additionally, the facility failed to ensure accurate skin assessment for the resident, who developed blisters on both heels. Staff interviews revealed inconsistent understanding of pressure injury staging, with one LVN incorrectly stating that an intact blister on the heel was not a Stage 2 pressure injury, while the ADON confirmed it should be considered as such. The care plan addressed the need for a pressure-relieving device for the wheelchair but did not include an intervention for the bed, despite the resident's decreased mobility and incontinence, which were identified as contributing factors for further skin breakdown. Furthermore, the facility did not follow the physician's order for a wound consult. Although a wound consult was ordered due to the Stage 3 pressure injury, staff interviews and record reviews confirmed that the order was not followed up or completed. The LVN responsible was unaware of the order, and the wound physician had not been consulted for the resident. These failures had the potential to contribute to the deterioration of the resident's existing pressure injuries and the development of new ones.