Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer and did not ensure that appropriate interventions were consistently in place for a resident at risk. A resident, who was totally dependent on staff for mobility and care, developed a new deep tissue injury on the right heel that was discovered by the primary care provider during rounds. Prior to this, staff documentation indicated no new skin issues, and the resident had reported heel pain to the provider but not to other staff. The resident had multiple diagnoses, including anemia, heart failure, renal insufficiency, malnutrition, and asthma, and was identified as being at risk for skin impairment and pressure ulcers. The care plan was updated to include the use of a pressure-relieving boot for the resident's right heel after the ulcer was discovered. However, observations showed that staff did not consistently implement this intervention. On several occasions, the resident was observed in bed with his heels resting directly on the bed surface and the protective boot not in use, despite care plan instructions. Staff interviews revealed a lack of awareness regarding the resident's pain and the development of the sore, and there was uncertainty about whether staff should have identified the issue sooner. Documentation and policy review indicated that while the facility had protocols for assessing risk and providing wound care, there was a lack of clear guidance on staff responsibility for following through with prescribed interventions. The resident's electronic chart showed no documentation of skin issues in the period leading up to the discovery of the ulcer, and staff were not consistently monitoring or documenting the use of pressure-relieving devices as required by the care plan.