Failure to Provide Pressure-Relieving Device for Resident with Contractures
Penalty
Summary
A resident with a history of severe cognitive impairment, hemiplegia, hemiparesis, and contractures was not consistently provided with a pressure-relieving device between the knees, despite being dependent on staff for all functional abilities and having existing pressure ulcers. The resident was observed on multiple occasions with contracted legs drawn up tightly toward the buttocks and knees together, without any pressure-relieving device in place between the knees. During care observations, staff were seen positioning the resident with a foam wedge under the knee or a folded flat sheet between the knees, but not with a dedicated pressure-relieving device. The wound care nurse confirmed that she was not aware of any pressure-relieving device being used between the resident's knees. These findings indicate that the facility failed to ensure appropriate pressure ulcer prevention measures for this resident.