Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident who was dependent for mobility and transfers and had no cognitive deficits. Despite a care plan that required turning and repositioning every one to two hours, the resident was not consistently turned or repositioned, as evidenced by the resident's own statements and observations by surveyors. The resident reported not being turned or pulled up for extended periods and expressed concerns about poor care and fear of being left in pain. Multiple progress notes and wound evaluations documented the development of new, in-house acquired pressure ulcers, including stage III and unstageable wounds, as well as a re-opened pressure ulcer. The resident was also observed to be incontinent and in the same position for several hours during the survey. The medical record review showed that the resident was admitted with intact skin and no wounds, but subsequently developed several pressure ulcers over time, with slow healing noted. Staff interviews indicated that the resident sometimes refused a pressure-reducing mattress and could turn himself slightly, but the care plan interventions for regular turning and repositioning were not consistently implemented. Facility policy required standards of practice to prevent or reduce pressure injuries, but these were not followed, resulting in the resident developing multiple pressure ulcers while under facility care.