Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A resident with diagnoses of osteoarthritis and dementia was identified as being at high risk for developing pressure ulcers, as indicated by a Braden Assessment. The resident's nursing care plan specified that she should only remain in her wheelchair with foam for a maximum of two hours at a time. However, multiple observations throughout the day revealed that the resident remained seated in her wheelchair in her bedroom for extended periods, far exceeding the two-hour limit outlined in her care plan. Interviews with facility staff, including a CNA and a licensed nurse, confirmed that the resident had not been assisted out of her wheelchair as required, and there was no documentation indicating that the resident refused care. The Director of Nursing also acknowledged that the care plan should have been implemented to prevent pressure ulcer development. The facility's policy on skin and wound monitoring emphasized the need for staff to implement and monitor interventions to prevent pressure injuries, which was not followed in this instance.