Failure to Prevent and Manage Pressure Ulcers and Inappropriate Use of Pressure-Relieving Equipment
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure ulcers for two residents. One resident, who was chairfast, incontinent, and totally dependent for activities of daily living, was admitted with intact skin but developed a facility-acquired unstageable pressure ulcer on the sacral area. Documentation and interviews confirmed that the resident did not have a wound upon admission, and the wound was first identified by staff, who noted moisture-associated skin dermatitis. The resident later required hospitalization due to wound infection, with hospital records indicating the presence of osteomyelitis and exposed bone. There was no documentation indicating that the wound was unavoidable, and the resident reported that staff did not clean or reposition her as needed. Another resident, who had multiple pressure ulcers and was severely cognitively impaired, was observed lying on a low air loss mattress that was set at a weight significantly higher than the resident's actual weight. Both the RN and the wound care nurse confirmed that the mattress should be set according to the resident's weight, and that an incorrect setting could result in a hard surface, impairing wound healing. The resident's care plan and physician orders specified the use of a pressure redistribution mattress, but the mattress was not set appropriately, contrary to manufacturer instructions and facility policy. Facility policies required that all residents at risk for skin breakdown receive appropriate care, including regular skin assessments, timely reporting of changes, and repositioning at least every two hours for those unable to reposition themselves. The facility's failure to follow these protocols and ensure proper use of pressure-relieving equipment resulted in the development and worsening of pressure ulcers for two residents, one of whom required hospitalization and surgical intervention.