Failure to Provide Pressure Ulcer Care and Implement Pressure-Reducing Devices
Penalty
Summary
Surveyors identified that the facility failed to follow physician orders and provide appropriate pressure ulcer care for three residents with pressure injuries. Facility policy required prompt assessment, evidence-based interventions, and the use of pressure-reducing mattresses for residents at risk or with existing pressure ulcers. However, medical record reviews and observations revealed that prescribed wound treatments were missed on multiple occasions for all three residents, and pressure-reducing mattresses were not properly implemented or maintained as ordered. For one resident with diabetes, anemia, and hypertension, there were missed daily wound treatments for both an unstageable pressure ulcer on the left buttock and a stage 3 pressure ulcer on the sacrum, as documented in the Treatment Administration Record. Observations showed that the resident's pressure-relief mattress lacked the required pump, and the appropriate equipment was not in place until after surveyor intervention. The DON confirmed that wound treatments should be completed and documented per physician orders, and that the correct mattress setup was necessary for wound care. Another resident with cerebrovascular disease and hemiplegia, who was at high risk for pressure ulcers, also had multiple missed wound treatments for a stage 3 sacral ulcer. This resident was observed on a bolster mattress rather than the required low air loss mattress until the equipment was changed during the survey. A third resident with severe malnutrition, diabetes, and Alzheimer's had missed wound treatments for a left heel injury and did not have a treatment order entered for a newly identified sacral deep tissue injury. Observations confirmed the absence of a pressure-relieving mattress until it was installed during the survey. The DON acknowledged that treatments were not initiated promptly and that documentation was lacking for required care.