Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
Facility staff failed to evaluate, monitor, and implement timely interventions for pressure ulcer prevention and wound healing for two residents. One resident, admitted with a right hip fracture and existing skin issues including a surgical incision, maceration to the sacrum, and redness on the left heel, was assessed as at risk for pressure ulcers and required pressure-relieving surfaces. Despite these risks, there was no evidence that staff implemented interventions to prevent further skin breakdown on the left heel. The resident subsequently developed a stage 3 pressure ulcer on the left heel, which worsened over time. Treatment orders were not obtained promptly, and wound care was not initiated until several days after the ulcer was identified, resulting in a decline in the wound's condition. Another resident, with moderate cognitive impairment and extensive care needs, was also identified as at risk for pressure ulcers and had interventions in place on the care plan, such as regular repositioning and pressure-reducing surfaces. However, an open area was noted on the left side of the back, and later, open wounds were observed on both the left back and sacrum. There was no documentation of wound resolution, no treatment orders for these wounds, and the wounds had not been measured or assessed as required. Staff confirmed that these wounds had not been properly evaluated or treated. The facility's own policy requires a systematic approach to pressure injury prevention and management, including prompt assessment, intervention, and monitoring. However, in both cases, staff did not follow these protocols, resulting in unaddressed and worsening pressure ulcers. The deficiencies were confirmed through record review, staff interviews, and direct observation.