Failure to Prevent and Monitor Pressure Ulcers Due to Inadequate Assessment and Repositioning
Penalty
Summary
The facility failed to provide necessary care and services to prevent and monitor pressure ulcers for three residents. For one resident with multiple diagnoses including dementia, Parkinson's disease, and malnutrition, staff did not accurately assess or document the presence of open wounds on the toes. Despite visible wounds observed by surveyors, weekly skin assessments and care plans did not reflect these findings, and nursing staff were unaware of the wounds until prompted by surveyors. There were no active wound care orders in place, and the care plan interventions were not effectively implemented. Two other residents, both at risk for pressure ulcers due to impaired mobility and other medical conditions, were not consistently turned or repositioned as required by their care plans and facility policy. Observations showed that one resident remained in the same position for three hours without intervention, and another was left in bed for over four hours without repositioning. Documentation confirmed infrequent repositioning, and staff interviews acknowledged that the expected frequency of turning was not met due to staffing issues. Additionally, for one resident with a left hip wound, the ordered intervention to cover the wound with a dry dressing was not followed, and the wound was left exposed to friction from an incontinence brief. Facility policies and standard care references required regular skin inspections and repositioning for residents with dependent mobility, but these standards were not adhered to, resulting in inadequate pressure ulcer prevention and care.