Failure to Implement and Document Pressure Ulcer Prevention and Care Interventions
Penalty
Summary
A resident with multiple diagnoses, including altered mental status, muscle weakness, atherosclerotic heart disease, and congestive heart failure, was admitted to the facility with a stage 2 pressure injury to the coccyx. Upon admission, the resident was assessed as high risk for pressure injuries using the Braden Scale and required substantial assistance for bed mobility, personal hygiene, and transfers. Despite these findings, there was no evidence that preventative interventions, such as an air mattress or a scheduled turning and repositioning regimen, were initiated or documented in the days following admission, as required by facility policy. The resident's care plan, initiated five days after admission, included interventions for pressure injury prevention and treatment, but physician orders and nursing documentation did not reflect the implementation of these interventions. The pressure injury progressed to an unstageable wound, and a new facility-acquired unstageable pressure injury developed on the resident's left heel. Throughout the resident's stay, there was a lack of documentation indicating that an air mattress was provided or that a turning and repositioning schedule was followed, even after the wounds worsened and new wounds developed. Additionally, weekly skin observation tools were either not completed or not documented as required by facility policy. Interviews with facility staff, including the DNS, wound physician, and wound nurse, confirmed that interventions such as air mattress placement and frequent turning and repositioning should have been implemented immediately upon admission and after wound deterioration. Staff were unable to explain why these interventions were not ordered or documented. The facility's policy clearly directed these interventions for residents with stage 2 or greater pressure injuries, but the required actions were not taken or recorded, leading to the identified deficiency.