Failure to Provide Pressure-Relieving Device for At-Risk Resident
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for one resident. According to the facility's policy, nursing staff are required to assess and document significant risk factors for pressure ulcers and implement appropriate interventions. A review of the resident's records showed that the individual was at risk for developing pressure ulcers, as indicated by a Braden Score of 18, and had a care plan intervention to place a cushion on the seat of his wheelchair. The resident had multiple diagnoses, including dementia, epilepsy, abnormal posture, melanoma of the scalp, and age-related disability, and used a wheelchair for ambulation. Despite the care plan intervention, observations on multiple occasions revealed that the resident's wheelchair did not have a pressure-reducing device in the seat. The wheelchair was observed at the bedside without a cushion, and Velcro was present where a cushion should have been attached. The DON confirmed that the resident previously had a cushion in the chair and acknowledged that it was needed but not present during the observations. This failure to ensure the presence of a pressure-relieving device in the wheelchair constituted a deficiency in pressure ulcer prevention care.