Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, diabetes mellitus, muscle weakness, and incontinence developed a Stage 3 pressure ulcer. The resident was assessed as being at moderate risk for pressure ulcers and was dependent on staff for mobility and repositioning. Despite care plans and wound management recommendations specifying the need for regular turning, repositioning, and floating of the heels to prevent further skin breakdown, these interventions were not consistently implemented. Multiple observations over several days showed the resident lying in bed on her back with her heels resting directly on the bed surface, rather than being floated on pillows as required. There was no documentation in the clinical record indicating that the resident refused these interventions. Staff interviews confirmed that the resident did not refuse care and was dependent on staff for activities of daily living, including repositioning and heel offloading. The facility's own policy required redistributing pressure, including offloading heels, as part of basic pressure injury prevention. However, the care plan lacked documentation of specific interventions such as turning, repositioning, or floating heels after the development of the pressure ulcer. Despite repeated discussions of preventive measures with staff, the necessary interventions were not observed to be in place, leading to the deficiency.