Failure to Prevent and Properly Manage Pressure Ulcers
Penalty
Summary
A resident with multiple comorbidities, including chronic obstructive pulmonary disease, congestive heart failure, malnutrition, muscle weakness, and peripheral vascular disease, was admitted to the facility and identified as being at risk for pressure ulcers. The resident was always incontinent of urine and frequently incontinent of bowel, but was not on a toileting program. The care plan included interventions such as regular turning and repositioning, use of a pressure-reducing mattress, and proper positioning techniques. Despite these interventions, the resident reported that staff did not always have time to get him out of bed and that ordered Zinc Oxide was not consistently applied to his buttocks. On assessment, the resident was found to have developed stage II pressure ulcers on both buttocks and the sacrum, despite a skin check the previous day indicating intact skin. The resident also reported that his mattress had a hole, causing him to sink through and rest directly on the metal frame, which caused pain. He stated that he had reported this issue to the Maintenance Director multiple times, but no action was taken. Staff interviews confirmed the mattress was in poor condition and that the resident had not been out of bed recently, with the mattress taking the brunt of the pressure. During wound care observation, the Wound Care Nurse failed to rinse the soap from the resident's skin and did not perform hand hygiene between glove changes. The soap used was found to require rinsing according to manufacturer instructions, which was not done. Additionally, the wash basin used for wound care was improperly stored uncovered in a shared shower area, and an unlabeled urinal was also stored improperly, raising infection control concerns. The Wound Care Nurse admitted to not knowing the product in the soap dispenser and acknowledged the error after reading the instructions.