Failure to Prevent and Treat Pressure Ulcers and Complete Timely Wound Assessments
Penalty
Summary
The facility failed to implement necessary interventions to prevent and treat pressure ulcers and did not complete initial wound assessments for three residents with pressure ulcers. For one resident with multiple comorbidities, including diabetes, morbid obesity, and chronic kidney disease, the care plan required a specialized air mattress and repositioning every two hours. However, the resident was observed without the required air mattress on multiple occasions and remained in a wheelchair for extended periods. The resident and a family member confirmed the absence of the air mattress and prolonged time spent in the wheelchair. The Assistant Director of Nursing verified that the resident should have had a special mattress and regular repositioning, which was not provided. Another resident, who was dependent on staff for mobility and incontinent of bowel and bladder, had a history of a stage four coccyx pressure ulcer that had healed but subsequently reopened as a stage three ulcer. The care plan required turning and repositioning every two hours, but the resident was observed sitting in a wheelchair for several hours without being offered to lie down. Staff confirmed the resident was not repositioned as required. Additionally, there was no documented assessment of the reopened wound at the time it was first identified, with the initial assessment only completed two days later. The nurse responsible for the resident's care acknowledged the lack of timely documentation, and the Assistant Director of Nursing confirmed the absence of an initial wound assessment prior to the documented date. A third resident, who was dependent on staff for lower body dressing and turning in bed, had a right heel pressure ulcer and was supposed to use pressure relieving boots while in bed. The resident was observed in bed without the boots, with heels directly on the mattress, and the boots were found in the wheelchair. The CNA assigned to the resident was unaware of the need for pressure relieving boots and only applied them after being prompted. The care plan required the use of these boots, and the Assistant Director of Nursing confirmed this intervention was not followed. Additionally, there was no documented assessment of the resident's right heel pressure ulcer upon readmission, with the first assessment completed several days later. The facility's policies required timely notification and documentation of wounds, which was not adhered to in these cases.