Failure to Prevent and Treat Pressure Ulcer in At-Risk Resident
Penalty
Summary
A resident with multiple comorbidities, including chronic kidney disease, hemiplegia, venous insufficiency, and frail skin, was identified as being at risk for pressure ulcers based on Braden Scale assessments. Despite care plans outlining the need for daily skin observation, frequent position changes, and the use of pressure-reducing devices, the resident developed an open area on the left inner buttock cheek, approximately half an inch in diameter with red tissue at the center. This area was observed without a dressing, and staff interviews revealed that the resident often remained in his wheelchair for extended periods, with limited assistance from staff in repositioning or transferring him. Documentation and assessments failed to identify or address the new skin issue in a timely manner. Weekly skin checks and shower sheets did not document the open area prior to its discovery, and skin evaluation forms repeatedly marked preventative interventions as "not applicable" or "inapplicable." When the open area was finally assessed by a nurse, it was noted that no skin incident report or treatment order had been initiated, and the required notifications and care plan updates had not been completed as per facility policy. Further observations revealed that the resident's wheelchair cushion was nearly flat, and staff were unsure if it was an appropriate pressure-reducing device. The resident reported significant discomfort and stated that staff rarely assisted with repositioning, despite his requests. The facility's policy required thorough assessment, timely intervention, and the use of pressure-redistributing surfaces for residents at risk, but these measures were not consistently implemented, resulting in the development of a stage II pressure ulcer.