Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement interventions to prevent the development of new pressure ulcers for a resident with multiple risk factors. The resident had a history of right tibia fracture, type 2 diabetes, morbid obesity, and was incontinent of stool. Upon admission, the resident was assessed as cognitively intact and at moderate risk for pressure ulcers according to the Braden Scale, with subsequent assessments indicating high risk. Despite these risk factors and recommendations from wound care specialists, the resident's care plan did not include specific interventions for the prevention of skin breakdown. Observations and interviews revealed that the resident was not consistently repositioned according to the recommended schedule. The resident was observed lying in the same position for extended periods, and staff interviews confirmed that repositioning was not performed every two hours as required. Additionally, heel protectors were not consistently applied to both heels, and the resident's right heel was found resting on the bed without protection. The facility's own policy required individualized repositioning schedules and the use of support devices for residents at risk, but these measures were not fully implemented for this resident. Documentation showed that the resident developed new pressure ulcers, including an unstageable ulcer on the left heel and a stage 3 ulcer on the left gluteus, while under the facility's care. Wound care notes and staff interviews confirmed that the resident required assistance with mobility and repositioning, yet these interventions were not reliably provided. The director of nursing acknowledged the absence of a care plan for skin breakdown prevention and confirmed that the resident should have had heel protectors on both feet and been repositioned every 1-2 hours.