Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
A resident with a history of left femur fracture, diabetes mellitus, and dementia was admitted to the facility and identified as being at very high risk for developing pressure ulcers. Initial assessments and care plans documented the resident's impaired mobility, dependence on staff for bed mobility, and risk factors such as incontinence and comorbidities. Despite these documented risks, the resident did not receive consistent repositioning, as evidenced by gaps and omissions in the positioning documentation, with 42% of opportunities for repositioning either left blank, marked as not applicable, or coded as not done. The facility's policies required identification, assessment, and implementation of interventions for residents at risk of pressure ulcers, including regular skin inspections and care plan updates based on risk assessments. However, after a significant drop in the resident's Norton Scale score indicating very high risk, no new or revised interventions were implemented in the care plan. Interviews with staff revealed a lack of awareness regarding specific interventions such as heel offloading, and the resident did not receive an air mattress until after the development of a pressure injury. The resident subsequently developed a deep tissue injury on the left heel, which was confirmed by nursing notes and a wound physician's evaluation. The injury was attributed to pressure related to immobility, and the documentation indicated that the resident's skin was intact upon admission except for a surgical incision. The failure to consistently reposition the resident and to update care interventions in response to increased risk directly led to the development of the pressure injury.