Failure to Implement and Document Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received wound preventative measures as ordered, resulting in the development of a stage 2 pressure ulcer on the coccyx. The resident, who had a history of an intertrochanteric fracture with surgical repair, protein-calorie malnutrition, panic disorder, and hypokalemia, was assessed as being at moderate risk for pressure ulcers. The resident was also noted to be occasionally incontinent of urine and always incontinent of bowel, with moisture-associated skin damage to the buttocks and groin documented at admission. Despite care plans and physician orders indicating the need for regular skin assessments and the application of zinc oxide for skin maintenance, documentation from CNAs and nursing staff did not reflect any skin issues or changes for the resident over several weeks. Shower sheets and skilled services documentation consistently failed to note any redness, rash, or breakdown, even though the resident was at risk and had existing skin concerns. The facility's policy required frequent skin inspections and prompt reporting of any changes, but these procedures were not followed. Interviews with staff revealed that CNAs were not consistently documenting skin assessments or reporting changes, and there were acknowledged challenges with training and compliance among newer CNAs. Both the Director of Staff Development and the Administrator confirmed that staff did not adhere to the facility's skin assessment policy, and this lack of assessment and documentation contributed to the development of the pressure ulcer.