Failure to Implement Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The facility failed to implement and maintain appropriate interventions to prevent and treat pressure ulcers for a resident identified as being at risk. The resident, who had diagnoses including hemiplegia, dysphagia, and chronic pain syndrome, was assessed as severely cognitively impaired and at risk for pressure ulcers, but had no unhealed ulcers at the time of the initial assessment. Subsequent provider notes documented the development and ongoing presence of a deep tissue injury with eschar on the resident's right heel, with specific orders to offload pressure using heel protectors and to complete wound treatment twice daily. Despite these orders, multiple observations revealed the resident lying in bed without heel protectors, with the right heel in direct contact with the mattress. Staff, including a registered nurse, failed to apply the heel protectors during wound care, and the DON confirmed that staff were expected to ensure residents with pressure ulcers wore boots, locating alternatives if necessary. The facility's policy referenced surveillance for pressure injuries but did not specify interventions for prevention or treatment, and staff did not consistently follow the care plan directives to offload the resident's heel.