Failure to Develop and Implement Comprehensive Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address offloading and pressure relief for a resident who was at risk for pressure injuries while sitting in a wheelchair. Upon admission, the resident had no pressure injuries to the sacrococcyx area and was admitted with multiple diagnoses, including post laminectomy syndrome, spinal cord disease, and cancer. The resident was dependent on staff for toileting and bathing and required assistance for mobility, with no feeling in the lower body due to spinal surgery. Over the course of the resident's stay, documentation showed the development and deterioration of a pressure injury on the sacrococcyx area, progressing from no injury to a stage two, and eventually to an unstageable pressure injury. Interviews with staff and family revealed that the resident frequently sat in a wheelchair for extended periods while visiting with family, sometimes without appropriate padding or repositioning. Staff confirmed that there were no specific care plan interventions or physician orders in place to address offloading or pressure relief while the resident was in the wheelchair, despite the resident's inability to reposition independently. The Director of Nursing acknowledged that the care plan did not include interventions for offloading pressure while the resident was in bed or in the wheelchair, and that care plans are essential for guiding care and preventing further skin breakdown. The facility's policy required care plans to be updated to reflect current interventions, but this was not done in the resident's case, contributing to the progression of the pressure injury.