Failure to Assess, Document, and Implement Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident. Specifically, the facility did not document assessments or obtain treatment orders for newly identified pressure ulcers, did not update the care plan to include pressure ulcers or pressure relieving interventions, and did not timely implement physician-ordered treatments. Observations showed the resident sitting in a stationary chair without a therapeutic cushion on multiple occasions, despite having pressure ulcers on the sacrum and heel. Staff interviews confirmed that pressure relieving interventions, such as wedge cushions or pressure relieving cushions, were not consistently used, and documentation of repositioning and skin assessments was lacking. Record review revealed that the resident was dependent on staff for mobility and incontinence care, had significant weight loss, and was at risk for pressure ulcers according to Braden assessments. The care plan only included general skin integrity monitoring and did not address specific interventions for pressure ulcer prevention or treatment. Physician orders for pressure relieving devices and treatments were not implemented as directed, and there were delays in starting prescribed treatments such as zinc cream. Initial assessments and documentation for new wounds, particularly to the heels, were missing, and there was no evidence that the physician was notified or that preventative measures were put in place in a timely manner. Further, staff interviews and documentation confirmed that weekly skin assessments were not consistently performed or recorded, and the care plan was not updated to reflect the resident's current condition or interventions. The Assistant DON acknowledged the lack of documentation and implementation of pressure relieving interventions, as well as missing shower sheets and incomplete wound assessments. These failures resulted in inadequate monitoring and management of the resident's pressure ulcers.