Failure to Implement Pressure Ulcer Prevention for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with significant medical conditions, including Parkinsonism, scoliosis, and severe cognitive impairment, was not provided with appropriate preventative care and services for pressure injuries. Despite a Braden Scale assessment indicating a high risk for pressure ulcers, the resident's care plan did not reflect this risk, and there were no meaningful interventions tailored to her needs. Observations over two days showed the resident remained in the same position in bed for extended periods, with her legs elevated on pillows and her heels offloaded, but without regular repositioning. Multiple staff interviews revealed a lack of awareness and implementation of repositioning protocols. Certified Nursing Assistants (CNAs) reported either not seeing any skin issues or not having orders to reposition the resident, despite the Director of Nursing's expectation that all bedbound residents be repositioned every two hours. The resident herself reported discomfort and pain, rating it as 7 out of 10, and was observed with a large, blanchable, reddened/purple area on her coccyx. Staff only repositioned her after the area was noted, and there was no documentation of consistent repositioning prior to this. The facility's policy required the interdisciplinary team to develop a care plan with measurable goals and evidence-based interventions for residents at risk of pressure injuries. However, the care plan for this resident did not address her high risk status, and staff failed to implement routine preventative measures such as regular repositioning. This lack of adherence to both the care plan and facility policy led to the development of a significant pressure area and ongoing discomfort for the resident.