Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of facility-acquired pressure ulcers for a resident with multiple risk factors, including osteoarthritis, weakness, and incontinence. Despite being identified as at risk for pressure injuries, the resident was not placed on a turn and reposition schedule, and the electronic health record lacked documentation of such a program. The care plan directed staff to assist with repositioning as needed, but routine repositioning was not implemented until after the wounds had progressed. Additionally, the facility did not provide a low air loss mattress or other standard interventions until the pressure ulcers had worsened. Wound monitoring and documentation were inadequate following the initial development of skin issues. Weekly skin assessments failed to identify or document the presence of wounds until after the resident and their representative reported concerns. When wounds were identified, staff did not consistently measure or assess the wounds for infection, drainage, or peri-wound condition, and there was a lack of evidence that physician orders for wound care were carried out as documented in the medication and treatment administration records. Communication among staff regarding wound status and interventions was inconsistent, and there was a gap in wound assessments due to improper training of the responsible nurse. Nutritional interventions to support wound healing were not implemented promptly, and the resident's wounds progressed to Stage 3 pressure injuries with exposed adipose tissue and signs of infection. The wounds increased in size and severity before appropriate interventions, such as frequent repositioning and specialized mattresses, were put in place. The resident ultimately developed a fever and was transferred to the hospital with suspected sepsis secondary to wound infection.