Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A resident with multiple complex medical diagnoses, including hypertensive heart disease with heart failure, HIV, COPD, acute myocardial infarction, and cerebral infarction, was admitted to the facility and assessed as being at moderate risk for pressure ulcer development. The resident's care plan identified the potential for pressure ulcer development and included interventions such as keeping the bed as flat as possible, using a pressure-relieving device on the bed and chair, and repositioning with assistance. Despite these documented interventions, staff failed to implement them consistently. On assessment, a new Stage 2 pressure ulcer was discovered on the resident's left buttock, which was determined to be acquired in-house. Staff interviews and observations revealed that the resident was often up in a wheelchair without a pressure-relieving cushion or device, contrary to the care plan. The resident reported having had a cushion previously but was unsure of its current whereabouts and stated that no action had been taken regarding the new pressure ulcer. Staff acknowledged encouraging the resident to use a recliner or cushion but did not ensure these interventions were in place. Facility policy required regular assessment and implementation of interventions for pressure ulcers, but these were not followed, resulting in the development of a new pressure ulcer for the resident.