Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure appropriate pressure-relieving interventions were in place for two residents at risk for or with a history of pressure ulcers. For one resident with a history of sacral deep tissue injury and a current moderate risk for pressure ulcers, the low air loss mattress was set incorrectly at a setting far above the resident's actual weight. The wound care nurse confirmed that the mattress setting was too high, making it overly firm and increasing the risk of skin breakdown. The resident was found lying on her back, incontinent, and refusing to be repositioned, and a new stage 1 pressure ulcer was identified on her coccyx. The care plan required the mattress to be checked every shift, but this was not done appropriately, and the mattress was adjusted based on the resident's preference rather than clinical guidelines. For another resident with multiple wounds and a care plan requiring offloading of the feet with heel protectors or pillows, staff failed to ensure both feet were properly offloaded. The resident was observed in bed with only one offloading boot in place, while the other boot was not on the resident and was found on the nightstand. The CNA responsible for the resident was unaware of the need for both boots and did not notice the missing boot until it was pointed out. The resident's care plan and physician orders indicated the need for offloading due to immobility and existing wounds, but this intervention was not consistently implemented. Both cases demonstrate a lack of adherence to established care plans and physician orders regarding pressure ulcer prevention and management. Staff failed to ensure that pressure-relieving devices were used correctly and consistently, and did not follow facility policy requiring regular assessment and implementation of interventions to prevent the development or worsening of pressure ulcers.