Failure to Prevent and Treat Pressure Ulcers Due to Inadequate Assessment and Care Planning
Penalty
Summary
The facility failed to develop and implement appropriate pressure ulcer prevention and care interventions for three residents, resulting in the development and worsening of pressure ulcers. Specifically, the facility did not conduct required Braden Scale Pressure Ulcer Risk Assessments weekly for the first four weeks after admission and quarterly thereafter, as outlined in their own protocol. For each of the three residents reviewed, there were significant lapses in risk assessment documentation, with only a single Braden assessment completed in the past year for some residents, and no assessments after changes in condition or as required by policy. Additionally, the facility did not update or implement individualized care plans with necessary pressure-relieving interventions, such as the use of heel protector boots, low air-loss mattresses, or turning and repositioning schedules, even when residents were identified as being at risk or after physician orders were given. Observations revealed that residents with existing pressure ulcers were not provided with ordered pressure-relieving devices, and staff were unaware of the need for these interventions. In several cases, care plans did not reflect physician recommendations or orders for pressure ulcer prevention and treatment, and staff failed to ensure that interventions such as off-loading heels or using special mattresses were in place. The facility also failed to provide wound care treatments as ordered by physicians, with documented instances where scheduled treatments were missed. As a result of these failures, residents developed severe, facility-acquired pressure ulcers, including stage four ulcers that required surgical debridement. Interviews with staff and review of records confirmed that the lack of timely assessments, incomplete care planning, and failure to implement or follow physician orders directly contributed to the development and progression of pressure ulcers in these residents.