Failure to Implement Pressure Ulcer Prevention Measures After Resident Readmission
Penalty
Summary
A deficiency occurred when a resident at risk for pressure ulcers did not have appropriate preventative measures in place following readmission from the hospital. The resident, who had multiple medical diagnoses including rib and vertebral fractures, prostate cancer, diabetes, DVT, and pneumonia, experienced a significant decline in mobility and cognition after hospitalization. Despite these changes, the care plan was not updated to reflect the increased risk, and no new interventions were added after the resident developed three pressure ulcers. Observations over several days showed the resident consistently lying in bed on his back without his heels elevated, despite staff interviews indicating that heel elevation was required. The resident had a low air loss mattress, but other preventative measures, such as regular repositioning and documentation of these interventions, were lacking. Staff interviews confirmed that the resident was largely bedbound and required substantial assistance, but there was no system in place for documenting repositioning, and the Braden Scale for pressure ulcer risk was not reassessed after the resident's condition changed. Medical record reviews revealed that the resident developed a sacral pressure ulcer, a right heel pressure ulcer, and a left hip pressure ulcer after readmission. Progress notes documented the emergence and progression of these wounds, as well as the treatments applied. The Director of Nursing confirmed that there was no facility policy on the prevention of pressure ulcers, further contributing to the lack of consistent preventative care for the resident.