Failure to Address Pressure Ulcer Risk and Prevention in Resident Care Plan
Penalty
Summary
The facility failed to recognize and address the risk of pressure ulcer development for a resident with multiple medical conditions, including type 2 diabetes mellitus, seborrheic dermatitis, schizoaffective disorder, and COPD. Despite the resident being identified as at risk for pressure ulcers and having a Braden Scale assessment completed, the care plan did not include a specific area for skin care or pressure ulcer prevention. The resident was independent with most activities of daily living and had a pressure-reducing device for the bed, but the care plan lacked individualized interventions to address skin integrity and prevent pressure injuries. The first observation of a Stage 2 pressure ulcer on the resident's upper right buttock was documented in the medical record, with subsequent physician orders for wound care and nutritional supplementation. Prior to the identification of the wound, there was no evidence that the care plan had been updated to include interventions for skin care or pressure ulcer prevention, despite the resident's risk factors. Staff interviews confirmed that the care plan should have included such interventions and that it was not updated after the wound developed. Facility policy required comprehensive assessment, individualized care planning, and implementation of interventions to prevent pressure ulcers, as well as regular monitoring and modification of care plans as needed. However, the facility did not follow these procedures for the resident, resulting in a failure to prevent the development of a pressure ulcer and to address the resident's risk in a timely manner.