Failure to Prevent and Identify Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for one resident identified as at risk for skin breakdown. The facility's policies required weekly skin observations by licensed nurses, daily skin checks by nursing assistants during personal care, and prompt notification of any skin impairment. Despite these policies, documentation and interviews revealed that the resident, who was admitted with multiple comorbidities and significant physical limitations, did not receive thorough and timely skin assessments. Progress notes indicated that the resident was unable to reposition independently and required a mechanical lift, yet there were gaps in the documentation of comprehensive skin assessments, particularly during the initial days following admission and while the resident was in isolation precautions. The resident's care plan identified them as at risk for pressure ulcers, with interventions such as weekly skin assessments, assistance with turning and repositioning, and heel protection. However, records showed that daily skin assessments documented no concerns, even though subsequent wound assessments identified multiple deep tissue injuries, including to the sacrum, right heel, and penis. Staff interviews confirmed that while wound care was eventually provided, initial assessments may not have been thorough, especially for areas not easily visible without repositioning the resident. The lack of early identification and intervention contributed to the development and worsening of pressure injuries. Further review of the resident's history showed that upon admission, there were no documented skin issues, but within ten days, multiple unstageable deep tissue injuries were present. Staff interviews revealed inconsistencies in the process for conducting head-to-toe skin assessments, particularly for residents with limited mobility or those in isolation. The facility's failure to consistently implement its own policies and ensure comprehensive skin assessments led to the resident developing significant pressure injuries that required further medical intervention.