Failure to Implement and Document Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to develop and implement adequate pressure ulcer prevention interventions for three residents with significant risk factors and existing pressure ulcers. For one resident with multiple comorbidities including Alzheimer's Disease, chronic kidney disease, and diabetes, a stage 4 pressure ulcer developed on the left knee while in the facility. Despite documentation of the wound as early as March, there was no treatment ordered or documented for the knee until over a month later, and the care plan did not address the knee ulcer or include specific interventions for the knees. Staff interviews revealed a lack of awareness regarding avoidable/unavoidable risk assessments for pressure ulcers, and documentation of prevention measures was incomplete or missing. Another resident with stage 3 and stage 4 pressure ulcers and functional quadriplegia was found on an air loss mattress set at a weight far above their actual weight, contrary to facility policy and staff training, which requires mattress settings to match the resident's weight for effective pressure ulcer prevention. A third resident, who had a wound doctor’s recommendation and family request for a low air loss mattress, was observed on a regular mattress instead of the prescribed pressure-relieving mattress. Facility policy states that such recommendations must be followed, but this was not done, and the resident did not receive the recommended intervention.