Failure to Reposition and Improper Briefing Practices Lead to Pressure Injury Risk
Penalty
Summary
The facility failed to provide appropriate care and services to prevent the development of new pressure injuries for one resident with significant risk factors. The resident was admitted with diagnoses including morbid obesity, quadriplegia, and chronic respiratory failure, and was assessed as being at risk for impaired skin integrity due to factors such as immobility, incontinence, and fragile skin. The care plan specified that the resident should be kept dry and clean and repositioned at least every two hours to prevent pressure injuries. Observations and interviews revealed that staff did not consistently reposition the resident as required. On one occasion, the resident was observed lying on their back in a high Fowler's position, and after being assisted by staff, was not repositioned to either side to relieve pressure. Staff interviews confirmed that the resident was not repositioned as per protocol, and that repositioning is necessary to prevent pressure injuries, especially for residents who are dependent for mobility and incontinent. Additionally, the resident was found to be double briefed, with the inner brief saturated with urine, contrary to facility policy and staff knowledge. Both nursing and administrative staff acknowledged that double briefing is not permitted as it increases heat and moisture, contributing to skin breakdown. Facility policies reviewed did not support double briefing and emphasized the importance of regular repositioning and perineal care to maintain skin integrity.