Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent pressure ulcers for two residents with decreased mobility and functional ability, resulting in the development of stage II pressure ulcers. For one resident, who was admitted with multiple comorbidities including diabetes, liver disease, cardiac and kidney disease, and was identified as high risk for pressure ulcers, the facility did not implement a timely turning/repositioning program or provide consistent use of pressure-relieving devices such as a heel boot. Documentation showed gaps in weekly skin assessments, inconsistent monitoring of heel boot compliance, and lack of documentation regarding the use and settings of a low air loss mattress. Nursing assistant records did not reflect adherence to or tolerance of repositioning interventions, and there was no evidence of ongoing assessment or re-evaluation of interventions. Observations revealed the resident was often found without the prescribed heel boot, and staff interviews indicated a lack of awareness regarding the resident's skin issues and required interventions. Another resident, who was severely cognitively impaired and had delusions, was care planned to have a foot cradle and wedge to minimize pressure to the feet due to a large blister on the left plantar surface. However, multiple observations showed the resident positioned in bed with both feet pressing against the baseboard, contrary to the care plan and Kardex directives. Staff interviews confirmed that residents should be turned and repositioned every two hours and that the Kardex should be followed, but these interventions were not consistently implemented for this resident. The facility's policy required preventative measures such as repositioning every 2-4 hours and the use of pressure redistribution mattresses, but these were not consistently carried out. Nursing documentation did not demonstrate a proactive approach to skin management, and there was a lack of thorough and ongoing skin assessments, observation for changes in risk factors, and evaluation of the effectiveness of interventions. These failures placed the affected residents and others at risk for the development of pressure ulcers.