Failure to Prevent and Manage Pressure Ulcers Due to Inadequate Assessment and Equipment Use
Penalty
Summary
The facility failed to consistently and accurately assess, monitor, and implement interventions to prevent skin breakdown for two residents at high risk for pressure ulcers. One resident was admitted with intact skin and a high Braden score risk, but developed a facility-acquired unstageable sacral pressure injury within weeks. There was no documented order or clear record of when a low air loss (LAL) mattress was implemented for this resident, despite its presence at the time of survey. The wound care nurse practitioner and wound care director confirmed the development of the pressure ulcer and noted the use of wound care treatments and nutritional supplements, but the initial preventive interventions and monitoring were not adequately documented or implemented per guidelines. Another resident with a history of surgical dehiscence and a full-thickness ankle wound was observed on an alternating air mattress that was not properly inflated due to the power cord being disconnected from the socket. The mattress was set at an incorrect weight and remained deflated in the upper middle portion, causing discomfort and pain for the resident. Staff were aware of the deflation but did not promptly resolve the issue, and the mattress was not providing the required pressure redistribution as per manufacturer guidelines. These failures in monitoring and equipment management contributed to inadequate pressure ulcer prevention and care for both residents.