Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
Surveyors identified that the facility failed to follow preventative wound care practices for several residents at risk for pressure ulcers. Specifically, two residents with low air-loss mattresses had their mattress settings incorrectly set much higher than their actual weights, contrary to manufacturer recommendations and facility policy. Documentation in the care plans for these residents lacked specific instructions regarding mattress settings or care, and staff interviews confirmed that mattress settings should be based on resident weight and checked each shift, but this was not consistently done. Additionally, two other residents who had physician orders and care plan interventions for heel protection did not have their heels floated or soft boots applied as required. Observations showed these residents lying in bed with their heels directly on the mattress, without any pressure-reducing devices in place. Staff interviews revealed that while nurses were responsible for ensuring these interventions were completed, the tasks could be delegated to CNAs, but verification and documentation were lacking. The facility's own policies on skin and wound management, as well as infection prevention and control, required the use of pressure-reducing devices, regular assessments, and adherence to specific interventions to prevent pressure injuries. Despite these policies and individualized care plans, the facility did not ensure that preventative measures were implemented as ordered, placing residents at risk for complications related to skin breakdown and pressure ulcers.