Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to implement its policies and procedures for pressure injury prevention and skin and wound management for a resident who was admitted with a history of a sacral pressure injury. Upon admission, the resident's risk for developing pressure ulcers was not accurately assessed, as the Braden Scale completed indicated no impairment in sensory perception or mobility, despite the resident being dependent on staff for most activities and having decreased movement in both lower extremities. The initial skin assessment performed by the admitting nurse did not identify any pressure injuries other than the sacral wound, and it was later revealed that the assessment may have been incomplete, as the nurse admitted to possibly not removing the resident's socks during the examination. Within approximately 22.5 hours of admission, the resident developed additional pressure injuries on the left buttocks/ischium and both heels, which were not present upon discharge from the hospital or noted during the initial skin check. A subsequent assessment by the treatment nurse identified a Stage 4 pressure injury on the left ischium, a Stage 3 pressure injury on the right gluteus, and deep tissue injuries on both heels. The discrepancies between the initial and follow-up assessments made it difficult to determine whether these injuries were acquired prior to or after admission, but the facility's own staff acknowledged that a lapse in turning and repositioning could result in the development of pressure injuries within a single shift. The resident's care plan did not include specific interventions to offload pressure from the heels, despite the presence of deep tissue injuries in those areas. The facility's policies required a comprehensive skin assessment upon admission, accurate risk assessment, and individualized care planning to prevent pressure injuries, including offloading and use of pressure-redistributing devices. These steps were not fully implemented, resulting in the resident developing additional pressure injuries and being at risk for further skin breakdown.