Failure to Implement Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
A deficiency occurred when a resident was admitted with a deep tissue injury (DTI) to the left buttock, blanchable redness to the coccyx and right buttock, and blanchable redness to both heels. Physician orders and facility protocols required the use of a low air loss mattress and heel boots to prevent further skin breakdown. Despite the mattress being delivered on the day of admission, the resident was observed on multiple occasions lying on a standard mattress instead of the prescribed low air loss mattress. Additionally, the resident was repeatedly found in bed without heel boots, with their heels resting directly on the mattress, contrary to the care plan and physician orders. The DON confirmed that such interventions are necessary for residents with wounds or at high risk for skin breakdown. Another deficiency was identified when a second resident with a stage 4 pressure injury to the left heel, who had physician orders for medi-honey and a dry dressing, was observed without a dressing on the wound during a wound assessment. The wound care nurse confirmed that the resident should have had a dressing in place and that dressing changes were ordered three times a week and as needed. The facility's policy required identification and implementation of treatment interventions for pressure injuries, which was not followed in this instance.