Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
A resident was admitted to the facility with a left femur fracture and no existing pressure injuries, as documented in the admission assessment. The resident was identified as being at risk for pressure sores, with a Braden Scale score of 15, and a care plan was established to assist with turning and repositioning as indicated. Despite these measures, the resident developed a pressure ulcer on the buttock, which progressed from a popped blister to a deep tissue injury, then to an unstageable wound, and ultimately to a stage four pressure ulcer. Staff interviews revealed that the resident required assistance with repositioning and that the resident had spent more than five hours in a wheelchair, exceeding the recommended maximum sitting time of one to two hours as noted in the physician's progress note. Further review indicated that the resident developed additional skin issues, including a blood blister on the coccyx and another deep tissue injury on the right buttock. Staff acknowledged the need for frequent repositioning and changing to prevent pressure ulcers, but the resident's care did not consistently reflect these practices. The facility's policy required individualized repositioning schedules based on risk factors, but the resident's clinical course and staff statements indicated lapses in implementing these preventive measures, resulting in the development and worsening of pressure injuries.