Failure to Prevent and Individualize Care for Pressure Ulcers in High-Risk Residents
Penalty
Summary
The facility failed to prevent the development of a wound in a resident with a tracheostomy who was identified as being at very high risk for skin breakdown and fully dependent on staff for care. This resident, who had diagnoses including respiratory failure, type II diabetes, and abnormal posture, was observed with a tracheostomy collar in place and was found to have an in-house acquired laceration on the left side of the neck. The wound was attributed to friction and moisture associated with the tracheostomy collar, and staff interviews confirmed that the collar and moisture contributed to the skin breakdown. Facility policy required individualized interventions for device-related pressure injuries, but the necessary preventive measures were not implemented to avoid this injury. Another resident, who was non-responsive and had multiple diagnoses including lumbar fracture, diabetes, and malnutrition, was found to have approximately 18 areas of impaired skin, including deep tissue injuries and pressure ulcers on both ears, elbows, sacrum, ischium, feet, and neck/head areas. Observations revealed that prescribed interventions such as a neck pillow for pressure relief were not in use, and the care plan did not include specific interventions for turning, repositioning, or the use of bolsters and neck pillows. Staff interviews indicated that while some interventions like heel boots and air mattresses were in place, individualized interventions for specific pressure areas, particularly the ears, were missing from the care plan. The facility's own policies required that skin and wound care interventions be individualized based on the resident's condition and that prevention protocols be implemented according to resident needs. However, the care plans for high-risk residents did not reflect all necessary or prescribed interventions, and staff did not consistently implement or document individualized measures to prevent pressure injuries. This lack of individualized care and failure to follow established protocols resulted in the development and worsening of pressure injuries in residents at high risk for skin breakdown.