Failure to Implement Care-Plan Interventions Leads to New Skin Breakdown
Penalty
Summary
A resident with a history of stroke, aphasia, and hemiplegia, who was totally dependent on staff for all activities of daily living and had severely impaired cognition, was identified as being at very high risk for pressure-related skin injuries based on a Braden Scale score of 8. Despite care plan interventions that included regular repositioning and the use of assistive devices to minimize skin breakdown, the resident was repeatedly observed resting in bed without positioning devices under their left arm. Multiple observations noted a strong odor in the room and under the resident's left breast, where open areas of skin breakdown were found. The care plan also required daily observation of skin condition and reporting of abnormalities, but the new skin breakdown under the left breast was not documented in the skin and wound evaluation prior to surveyor discovery. Further review revealed that the resident's left arm was nearly closed over the left breast, with no positioning device in place to aid in pressure reduction, and staff noted the resident sweated excessively. The facility's own skin management guidelines identified excessive perspiration as a risk factor for moisture-associated skin damage, yet these risks were not adequately addressed. The failure to implement care-planned interventions and to document and report new skin breakdown resulted in the development of multiple open areas under the resident's left breast, indicating a lack of adherence to professional standards of practice for the prevention and management of pressure ulcers.