Failure to Reassess and Update Interventions After New Pressure Injury
Penalty
Summary
The facility failed to comprehensively reassess and develop proactive interventions after a new pressure injury was identified in a resident with multiple medical conditions, including heart failure, hypertension, and multiple sclerosis. The resident was already at risk for pressure injuries and had an existing stage IV pressure ulcer that developed after admission. Despite the development of a new stage III pressure injury, there was no documented evidence of a comprehensive reassessment or updated interventions in the medical record. The care plan and interventions were not revised until after the survey began, and the required skin evaluation form was left incomplete. Interviews with staff revealed that the resident was largely independent in her care decisions, often refusing repositioning and other recommended interventions. Staff described the resident as dismissive and resistant to care, with a preference for remaining in bed and limited time spent in her wheelchair. Although the interdisciplinary team (IDT) discussed the resident's wounds and care plan, there was a lack of documentation regarding what interventions were considered, offered, or refused, especially after the new wound developed. The IDT notes provided were undated and lacked specific details about the reassessment process or any new interventions implemented. The facility's policy required a pressure ulcer risk assessment and completion of a skin evaluation form upon significant change, but the policy did not provide clear guidance on how a comprehensive reassessment should be conducted or documented. The director of nursing acknowledged that the medical record lacked evidence of a comprehensive reassessment and that proper documentation was important for continuity of care. The absence of a thorough reassessment and documentation following the development of a new pressure injury constituted the deficiency identified by surveyors.