Failure to Implement Pressure Injury Prevention and Care
Penalty
Summary
A deficiency occurred when the facility failed to implement professional standards of practice for pressure injury (PI) prevention and care for a resident who was admitted with a stage 1 PI and identified as high risk for further skin breakdown. Upon admission, the resident had a history of falls, cognitive impairment, decreased mobility, and a displaced femur fracture, all contributing to increased risk. The initial care plan lacked specific interventions for PI prevention, and there was no evidence of a turning and repositioning program being implemented, monitored, or reviewed. Additionally, education regarding the risks and benefits of repositioning and offloading was not documented as completed. Observations revealed that the resident was not repositioned or offloaded according to care plan requirements, with extended periods spent sitting on the buttocks in bed and in a recliner without the use of pillows or appropriate cushions. Staff interviews confirmed a lack of awareness and consistent implementation of PI prevention interventions, and documentation supporting the use of an air mattress or appropriate pressure relief cushions was not provided. The resident's PI worsened from a stage 1 to an unstageable wound during their stay, with staff noting increased redness and tissue damage. Continuous observation by the surveyor showed that the resident remained on the affected area for over four hours without repositioning, and staff did not consistently offer or encourage offloading or repositioning. The facility was unable to provide evidence that the current pressure relief cushions were suitable for an unstageable PI, and staff were unclear about the interventions in place. These failures resulted in actual harm to the resident, as evidenced by the progression of the pressure injury.