Failure to Implement and Document Individualized Pressure Ulcer Prevention Measures
Penalty
Summary
Facility staff failed to implement appropriate individualized interventions for a resident identified as at risk for developing pressure ulcers. Upon admission, the resident was noted to have redness to the groin and buttock, but the documentation did not specify the size or whether the redness was blanchable. Physician orders included daily and weekly skin checks, weekly Braden Scale assessments for four weeks, and application of a moisture barrier cream. However, staff did not complete the required weekly Braden Scale assessments as ordered, and the interim plan of care did not specify individualized interventions to address the resident's skin integrity risk. The comprehensive care plan also lacked specific measures for turning and repositioning, use of prescribed moisture barrier cream, and the pressure-reducing device, despite the resident's dependence on staff for mobility and hygiene. The resident later developed an open area on the sacrum, which was first identified as unstageable, prompting new interventions such as an alternating pressure mattress, urinary catheter, and scheduled turning and repositioning. Documentation revealed that staff did not consistently record turning and repositioning assistance both before and after these interventions were added to the care plan. Interviews with the attending physician and DON confirmed that appropriate interventions were not in place or documented prior to the development of the pressure ulcer, and that staff failed to follow physician orders and facility protocols for residents at risk of pressure ulcers.