Failure to Prevent and Manage Pressure Ulcers Due to Incomplete Assessment, Documentation, and Implementation of Preventative Measures
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for two residents who were at risk for pressure injuries. One resident was admitted with a shearing wound on the coccyx and was assessed as being at risk for pressure ulcers. However, the initial skin assessments and wound documentation were incomplete, and the physician was not notified when the wound worsened. Preventative measures, such as turning and repositioning every two hours, were not properly identified or implemented upon admission. The nurse responsible for wound care did not document wound measurements, location, or description after the initial assessment and admitted to missing required charting. There was also no evidence that the resident was turned every two hours or that refusals were documented. As a result, the resident's wound worsened, causing pain and requiring surgical intervention and wound vacuum placement at a hospital. Another resident, also at risk for pressure ulcers due to immobility and incontinence, developed a shearing wound on the coccyx and blanchable redness on both heels while in the facility. The skin assessments and wound documentation for this resident were incomplete, and interventions to prevent pressure ulcer development, such as turning every two hours and the use of heel lift boots, were not consistently implemented. Certified Nursing Assistants (CNAs) were unaware of the care plan requirements for turning and repositioning, and there was no documentation to show that these interventions were carried out. During observation, the resident was found with only one heel boot in place, and a deep tissue injury with eschar was discovered on the left heel. The nurse confirmed that the wound had worsened without proper documentation or notification. Interviews with nursing staff and the Director of Nursing revealed that documentation of turning and repositioning was not routinely performed, and changes in wound condition were not always promptly recorded or communicated to the physician. Facility policies required documentation of services provided, changes in condition, and timely notification of the physician, but these were not followed. The lack of adherence to care plans, incomplete documentation, and failure to implement preventative measures led to the development and worsening of pressure ulcers in both residents.