Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for three residents, resulting in the development and worsening of facility-acquired pressure ulcers. For one resident with a history of diabetes, impaired mobility, and cognitive impairment, the care plan was not updated with pressure-relieving interventions prior to the development of a right heel pressure ulcer. The resident did not receive routine skin checks, and Braden Scale assessments were not completed quarterly as required by facility policy. The resident's pressure-relieving boots were not consistently applied, and when used, did not have a heel off-loading cavity, failing to relieve pressure. This led to the development of a painful, unstageable pressure ulcer that required surgical debridement. Another resident, who was dependent on staff for mobility and transfers and at risk for pressure ulcers due to decreased mobility, incontinence, and morbid obesity, developed two stage two pressure ulcers on the buttocks. The resident was observed on a standard foam mattress rather than a pressure-relieving mattress as ordered in the care plan and physician orders. Staff were unaware of the open areas, and there was no documentation of the pressure areas in the medical chart until the ulcers were identified by the Director of Nursing. A third resident, severely cognitively impaired and dependent on staff for all activities of daily living, developed an unstageable deep tissue pressure injury to the right heel that continued to worsen. The care plan did not include pressure-relieving interventions, and although orders were in place for heel protectors and regular repositioning, these interventions were not consistently implemented. The resident was observed without heel protectors in both bed and wheelchair, and staff failed to ensure pressure was relieved as directed, contributing to the progression of the pressure ulcer.