Failure to Implement and Document Pressure Ulcer Prevention and Treatment Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents who were assessed to be at high risk for developing pressure ulcers. For one resident with multiple sclerosis and significant immobility, a blister was identified on the ankle by staff, but there was no immediate skin assessment, no timely implementation of a physician's order for treatment, and incomplete documentation regarding the wound's characteristics and progress. The weekly skin check was not performed as scheduled, and the treatment order for the blister was not implemented until five days after the area was first identified. Interviews with nursing staff and administration confirmed that the expected protocol was not followed, and the required documentation and monitoring were lacking. For another resident with dementia, a history of pressure ulcers, and severe cognitive impairment, the facility did not ensure that the care plan and physician's orders related to skin integrity were implemented. Observations revealed that the resident's feet and heels were not offloaded as ordered, and prescribed interventions such as air boots, foam dressings, and lambswool between all toes were not consistently in place. The resident was observed with blood blisters and redness on the feet and toes, and there was no documentation of treatment refusal. Staff interviews confirmed that the physician's orders were not being followed, and the resident's care plan interventions were not consistently implemented. The facility's own policy required systematic skin inspections, prompt assessment and intervention for skin issues, and thorough documentation of wound characteristics and progress. In both cases, there were failures to adhere to these protocols, including missed assessments, delayed or omitted treatments, and incomplete documentation. These actions and inactions directly led to the deficiencies cited by surveyors.