Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
Staff failed to provide adequate pressure ulcer prevention and care for two residents, resulting in the development and worsening of pressure ulcers. One resident, who was at moderate risk for pressure injury and had significant cognitive and physical impairments, was not consistently provided with required heel protectors as ordered. Observations showed the resident without protective boots, with feet unsupported and dangling while seated in a wheelchair for extended periods. Multiple open wounds and unblanchable red areas were noted on the resident's feet and heels, with staff unaware of the status or treatment of these sores. Documentation was incomplete, lacking timely updates on new wounds and notification to the physician or hospice regarding changes in skin condition. Another resident, with a history of stroke, dementia, and other chronic conditions, experienced repeated episodes of redness and later blackened and scabbed areas on the toes. Despite ongoing skin assessments documenting these changes over several weeks, there was a delay in notifying the care coordinator and physician, and interventions were not implemented promptly. The care coordinator was not aware of the skin condition until several weeks after initial signs were documented, and the director of nursing confirmed that earlier intervention should have occurred. The facility's policy required immediate notification and documentation of impaired skin integrity, which was not followed in these cases. Both cases demonstrated a failure to monitor, document, and respond to changes in skin condition as required by facility policy and care plans. Staff did not ensure that prescribed interventions, such as heel protectors and pressure-reducing devices, were consistently used, nor did they update care plans or notify appropriate medical personnel in a timely manner when new or worsening wounds were identified. These lapses contributed to the development and progression of pressure ulcers in residents who were at risk.