Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to properly identify, monitor, and prevent the development and worsening of pressure ulcers for two residents. One resident, with intact cognition and a very high risk for pressure ulcers as indicated by a Braden assessment, was observed lying in bed with both heels touching the bed and without protective boots. The resident reported not being turned or repositioned since the previous night, despite care plans requiring repositioning at least every two hours. Multiple pressure ulcers, including stage 3 and unstageable wounds, were documented as facility-acquired, and there was a lack of consistent and accurate wound documentation. Staff interviews confirmed that wound documentation was incomplete and that the resident's pressure ulcers should not have developed or worsened. Another resident, with severe cognitive impairment and a history of dementia and aphasia, experienced a lapse in routine skin assessments, with an 18-day gap between documented assessments. This resident developed a stage 3 pressure ulcer on the right ischial tuberosity, which progressed to a stage 4 ulcer. The resident's care plan included weekly skin assessments, but documentation showed that these were not consistently performed. The resident's family reported that the deterioration of the wound contributed to the resident's overall decline and eventual enrollment in hospice care. Facility policy required daily skin observation during care and weekly assessments by licensed nurses for patients without skin issues. However, the records and interviews revealed that these protocols were not followed, leading to delayed identification and inadequate management of pressure ulcers. The deficiency resulted in the development and worsening of pressure ulcers, including infection and deterioration of wounds, for the affected residents.