Failure to Provide Proper Pressure Ulcer Care and Equipment Settings
Penalty
Summary
Two residents experienced deficiencies in pressure ulcer care and prevention. One resident, admitted with a left femur fracture, cognitive impairment, and no pressure injuries, developed a stage 2 pressure injury (clear fluid-filled blister) on the right heel. The wound worsened to an unstageable pressure injury covered with slough. Despite a wound care recommendation to use medihoney and foam dressing, the treatment administration record showed only skin prep was applied, and the recommended treatment was not implemented. There was no documentation of an Interdisciplinary Team (IDT) meeting to address the worsening wound, nor was the attending physician notified of the change in the wound's status. A second resident, with severe cognitive impairment and a stage 3 pressure injury, was observed using a low air loss mattress intended for wound management. The mattress was set for a person weighing 250 pounds, while the resident's actual weight was 91 pounds. The treatment nurse confirmed the mattress was not set appropriately for the resident's weight, which is necessary for effective pressure redistribution and wound healing. The facility's policy required evidence-based interventions and appropriate support surfaces for residents at risk or with pressure injuries, but did not provide specific guidance on mattress settings. Both cases demonstrated failures to follow established protocols for pressure injury management, including prompt implementation of wound care orders, interdisciplinary assessment, physician notification, and proper use of pressure-relieving equipment. These inactions contributed to the deficiencies identified during the survey.