Failure to Provide Timely Pressure Ulcer Prevention and Care
Penalty
Summary
A resident with multiple comorbidities, including diabetes, immobility, and cognitive impairment, was admitted to the facility with existing pressure ulcers and was identified as being at risk for further skin breakdown. The resident required substantial to maximum assistance for mobility and personal care and was dependent on staff for transfers and repositioning. The care plan directed staff to use pressure-relieving devices and follow protocols for skin breakdown prevention, but it did not include specific interventions for repositioning or offloading until after the resident developed a new pressure ulcer on the left heel. Despite the resident's risk factors and care needs, documentation and staff interviews revealed uncertainty about whether pressure-relieving boots were in use prior to the development of the left heel ulcer. Staff could not confirm if turning and repositioning were consistently implemented or if these interventions were clearly communicated in the care plan. The resident developed a facility-acquired unstageable pressure ulcer on the left heel, which progressed in size and severity, eventually becoming necrotic and malodorous, and was later diagnosed as osteomyelitis by a hospital. The facility's records lacked evidence of timely care plan updates and did not provide a policy on pressure ulcer prevention. Staff interviews indicated gaps in communication and training regarding pressure ulcer prevention interventions. The care plan was not updated to include offloading and heel protectors until after the pressure ulcer had developed, and there was no documentation of a systematic approach to ensure at-risk residents received necessary preventive care.