Failure to Consistently Monitor and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to consistently monitor and assess the skin of residents at risk for or with existing pressure ulcers, as required by physician orders and facility policy. For one resident, observations revealed that heel boots intended to prevent pressure ulcers were not applied, and the resident's heels were in direct contact with the mattress. The specialty air mattress was set incorrectly for the resident's weight, and there were gaps in the completion of weekly skin assessments as ordered by the physician. The care plan lacked specific instructions regarding the mattress settings, and the intervention to float the heels was not consistently implemented. Another resident, admitted with a stage 3 pressure ulcer, was observed on a regular mattress rather than a pressure-reducing device as indicated in the care plan. The resident's medical record showed inconsistent completion of weekly skin assessments, with a significant gap of over two weeks without documentation. The care plan included an intervention for a low air loss mattress, but this was not in place, and staff were unclear about the rationale for this intervention. A third resident, with a history of pressure ulcers and multiple risk factors, also did not have weekly skin assessments completed as ordered. After readmission, there was a month-long gap without documented skin assessments, and multiple shower sheets indicated areas of redness or open skin that were not followed up by a nurse. Interviews with staff revealed confusion about the process for completing and documenting skin assessments, and discrepancies were noted between CNA shower sheets and nursing documentation, with no further assessment or follow-up on identified skin concerns.