Failure to Provide Pressure-Relieving Devices for At-Risk Resident
Penalty
Summary
The facility failed to implement appropriate interventions for a resident at moderate risk for pressure ulcers, as identified by a Braden Assessment score of 13 and a care plan that included the use of pressure-relieving devices and barrier creams. Despite documented risk factors such as Alzheimer's disease, impaired decision-making, urinary incontinence, and limited mobility, the resident was repeatedly observed sitting in a wheelchair or recliner without a pressure-relieving cushion. Staff interviews confirmed that the resident did not have a specialty cushion in either the wheelchair or recliner, and the resident frequently complained of pain and soreness in the buttocks area. The care plan specified the use of pressure relief mattresses and cushions, but these interventions were not consistently provided. Multiple observations over several days showed the resident with dark red/purple, fragile, and peeling skin on the buttocks and coccyx, and staff were seen performing incontinent care and applying barrier cream. The resident's representative also reported that the facility would not use cushions brought from home, and that the resident continued to complain of soreness. Nursing staff acknowledged the absence of a pressure-relieving cushion and stated that the cushion was missing. The facility's policy required the use of pressure-reducing devices for residents at risk, but this was not followed, resulting in the resident experiencing pain and skin breakdown.