Failure to Prevent and Manage Pressure Injuries Due to Inadequate Interventions and Documentation
Penalty
Summary
The facility failed to provide appropriate interventions to prevent the development and worsening of pressure injuries for two residents. For one resident with a history of diabetes, heart failure, and a recent left great toe amputation, a deep tissue injury developed on the left plantar foot while in the facility. Although the care plan included interventions such as heel suspension devices, a foot cradle, and a turning/repositioning program, there was a lack of consistent implementation and documentation. Staff interviews revealed confusion about when and how to apply these interventions, and the resident reported inconsistent use of protective devices. The clinical record lacked documentation of turning and repositioning, and staff were unclear on where to document these actions or how to verify if a resident was on such a program. Another resident, with diagnoses including diabetes, cerebrovascular accident, and dementia, experienced worsening of a Moisture Associated Skin Damage (MASD) area on the coccyx. The care plan directed staff to perform treatment as ordered and use pressure-reducing devices, but did not specify a turning or repositioning schedule. Documentation showed that wound care treatments were missed on several days, and the MASD area deteriorated before the ARNP was notified. The clinical record and care plan failed to include a positioning schedule, and staff interviews confirmed that they relied on the care plan for such instructions, which were absent. Policy review indicated that staff were expected to assess and document risk factors for pressure ulcers and implement appropriate interventions. However, neither resident had a positioning schedule documented in the Kardex, and there was a lack of documentation and follow-through on required interventions. The deficiencies were identified through observation, record review, and staff and resident interviews, which consistently showed gaps in the implementation and documentation of pressure injury prevention and care.