Failure to Provide Pressure-Relieving Devices for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary pressure ulcer prevention and treatment interventions for two residents, as required by their own policy and professional standards of practice. One resident with multiple comorbidities, including chronic kidney disease, diabetes, and morbid obesity, was identified as high risk for pressure ulcers and was receiving treatment for a stage 3 pressure injury and a suspected deep tissue injury. Despite this, the resident was repeatedly observed in her wheelchair without a pressure-relieving cushion, and staff confirmed that such a device should have been in place due to her current pressure ulcer. Another resident, also with significant health issues such as morbid obesity, reduced mobility, and muscle weakness, was assessed as being at moderate risk for developing pressure ulcers. This resident was observed multiple times sitting in a wheelchair without a pressure-relieving cushion and reported sitting in the wheelchair most of the day without being offered a cushion, despite expressing discomfort. The DON confirmed that a cushion should have been provided to reduce the risk of pressure ulcer development for this resident.