Failure to Prevent and Monitor Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for two residents. For one resident with anoxic brain damage and multiple contractures, staff did not consistently perform skin assessments during scheduled shower days or on days when bed baths were provided. Documentation showed missed showers and incomplete skin inspections. Additionally, the resident's care plan required turning and repositioning at least every two hours, but records indicated this was not done consistently, with significant gaps between documented repositioning times. Observations confirmed the resident was often found lying on his back for extended periods, and staff interviews acknowledged the importance of these interventions but revealed lapses in their execution and documentation. Another resident, who was dependent on staff for all activities of daily living and had a history of diabetes, gastrostomy, tracheostomy, and ventilator dependence, was at high risk for pressure injuries. This resident developed a Stage II pressure injury on the right shin, which was not promptly identified or reported by staff. Interviews with CNAs and restorative nursing aides revealed uncertainty about the onset of skin changes and inconsistent use of the facility's early warning documentation tools. The treatment nurse confirmed that the injury was discovered during physician rounds rather than through routine staff monitoring, and that earlier intervention could have prevented the progression of the wound. Facility policy required regular evaluation, reporting, and documentation of skin changes, as well as frequent monitoring of device-related pressure areas. However, staff did not consistently assess or report skin conditions under medical devices such as knee splints, and there was a lack of communication and documentation regarding abnormal findings. These failures in following care plans, performing scheduled assessments, and documenting and reporting skin changes contributed to the development and progression of pressure injuries in both residents.