Failure to Implement Pressure Ulcer and MASD Prevention Protocols
Penalty
Summary
The facility failed to implement appropriate pressure ulcer and moisture-associated skin damage (MASD) prevention and treatment interventions for a resident identified as high risk for pressure injuries. The resident, who had multiple diagnoses including cerebrovascular accident with hemiparesis and seizures, was dependent on staff for mobility and personal care. Physician orders and facility protocols required that the resident's heels be floated off the mattress using pillows under the calves, and that the resident be turned every one to two hours to prevent pressure injuries. However, observations on multiple occasions revealed that the resident's heels were in contact with the mattress, and staff interviews confirmed that the correct technique for floating heels was not consistently followed. Documentation and observation also showed that the resident was not consistently turned every two hours as required. Review of the turning protocol indicated multiple instances where the resident remained in the same supine position for extended periods, contrary to the physician's order and facility policy. Staff interviews confirmed the importance of regular turning for high-risk residents and acknowledged that the resident was not repositioned as frequently as required. Additionally, the facility failed to initiate and document appropriate treatment for the resident's MASD. The resident developed MASD in the groin and buttocks areas, but there was no evidence that the facility's MASD protocol was implemented when the condition was first identified. Observations and staff interviews revealed that moisture barrier cream was not applied to all affected areas, and required documentation, including photographs and initiation of the MASD protocol in the electronic medical record, was not completed in a timely manner. The facility's policy required documentation and specific interventions for skin impairments, which were not followed in this case.