Failure to Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide ordered treatments to prevent pressure ulcers and promote healing for a resident with significant risk factors. The resident had a history of chronic renal failure, significant cognitive decline, and was dependent on staff for mobility and hygiene. Despite being identified as high risk for pressure injuries, with a Braden score indicating severe risk and documented weight loss, the resident developed two facility-acquired pressure injuries on the right foot and a Stage 1 pressure ulcer, as well as a deep tissue injury. Physician orders and the care plan directed staff to apply Skin-prep and border foam dressings to the resident's right foot and buttocks on specific days, and to use heel protector boots every shift. However, multiple observations revealed that these treatments were not consistently provided. On several occasions, the resident was found without the required dressings on both the feet and buttocks. Staff interviews confirmed that the dressings were sometimes not applied as ordered, and one CNA stated that the resident had not had a dressing on the buttock for a long time. Administrative staff acknowledged that the dressings should have been in place and that staff were expected to follow treatment orders to prevent further decline. The facility's own wound prevention and management policy emphasized the importance of identifying residents at risk and implementing interventions to decrease pressure areas and promote healing, but these protocols were not followed for this resident.