Failure to Prevent and Manage Pressure Ulcer and Notify Provider and DPOA
Penalty
Summary
The facility failed to provide care in accordance with professional standards and its own policies to prevent the development and worsening of a pressure injury for a resident with multiple sclerosis and limited mobility. The resident was observed in bed for extended periods, with her position unchanged for several hours, and her heels resting directly on the bed surface despite care plan interventions requiring heel elevation and frequent repositioning. Staff interviews confirmed that the resident was to be repositioned at least every two hours, but observations showed this was not consistently implemented. Documentation review revealed that the resident developed two open sores in the coccyx area, which were not promptly reported to the provider or the resident's DPOA. There was a significant delay in notifying the provider (12 days after initial identification) and the DPOA (18 days after identification) of the pressure injury. Additionally, there was no documentation of new care plan interventions or treatment orders at the time the wounds were first identified, and the DPOA was not informed of subsequent treatment changes in a timely manner. Treatment records showed that ordered wound care was not consistently completed on several dates, and there was a lack of documentation regarding the implementation of new treatments. The facility's own policy required prompt notification of the provider and responsible party, timely implementation of treatments, and regular documentation and monitoring, all of which were not followed in this case. Family interviews further indicated a lack of communication regarding the resident's condition and care, with the DPOA unaware of the wound's status and treatment changes.