Failure to Implement and Document Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized pressure ulcer prevention and treatment program for a resident who was at risk for pressure ulcers due to multiple medical conditions, including chronic kidney disease, diabetes, and impaired mobility. Despite being identified as at risk and having care plans and physician orders in place for preventive measures such as skin prep, offloading boots, and pressure redistribution, there was a lack of consistent implementation and documentation of these interventions. The resident was dependent on staff for mobility and application of protective devices, yet there was no evidence that offloading boots were consistently used or documented, and CNAs were not directed to use them until months after the initial care plan was developed. A significant deficiency occurred when the resident developed an unstageable pressure ulcer on the left heel, which later progressed to a Stage IV ulcer requiring manual debridement. There was a failure to implement physician-ordered treatments in a timely manner, as orders for specific wound care products such as Mesalt and bordered dressings were not entered or followed for an extended period. Instead, only skin prep and betadine were applied for several days, contrary to the wound physician's recommendations. Documentation was also lacking regarding the rationale for treatment changes and the resident's wound status during critical periods. Interviews with staff revealed confusion and lack of clarity regarding the resident's compliance with care, with no documented evidence of refusal or non-compliance, despite some staff and physician notes suggesting otherwise. The resident was described as dependent on staff for care and did not refuse treatments, though she expressed discomfort due to ticklishness. The absence of proper documentation, failure to follow physician orders, and lack of consistent preventive interventions directly contributed to the development and worsening of the resident's pressure ulcer.