Failure to Implement and Monitor Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement preventive pressure ulcer measures and prevent new ulcers from developing for two residents. For one resident with a urinary catheter, observations revealed a left-sided penile erosion measuring 3 to 3.5 cm in length, attributed to the catheter. The catheter tubing was noted to be taut from the penis head to the left thigh, and the resident reported pain at the site. The resident also stated that the leg bag would become heavy and pull on the tubing, causing discomfort. During the observation, the LPN did not use hand sanitizer before donning gloves and had long artificial nails with jewelry attachments. The wound was confirmed to be facility-acquired, and the wound care nurse acknowledged the difficulty in measuring the wound accurately due to its location and the limitations of photographic documentation. The DON confirmed the erosion was caused by the catheter and was being treated in-house. For another resident, the facility failed to ensure the proper functioning of a prescribed air mattress intended to prevent pressure ulcers. The resident, who was dependent on staff for activities of daily living and had multiple comorbidities including diabetes, stroke, and muscle weakness, was observed in bed with an air mattress that was not plugged in and not functioning as intended. The plug was found to have a bent prong, preventing it from being plugged in. There was no documentation in the physician's orders or care records requiring staff to check the air mattress for functionality or to ensure it was set to the correct alternative pressure setting. Staff interviews confirmed that there was no established process for documenting checks of the air mattress prior to the surveyor's intervention. These deficiencies were identified through direct observation, staff and resident interviews, and record reviews. The lack of preventive measures and monitoring contributed to the development of a facility-acquired pressure injury in one resident and the risk of pressure ulcer development in another, both of whom were dependent on staff for care and at high risk for skin breakdown.