Failure to Consistently Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency was identified when staff failed to implement pressure ulcer prevention interventions for a resident with a history of a Stage IV pressure ulcer. Multiple observations over two days showed the resident lying in bed on their back with their heels flat on the mattress and without positioning wedges or pillows in place, despite care plans and wound care notes specifying the need for heel offloading and frequent repositioning. The resident was also noted to have impaired cognition and required staff assistance for bed mobility and transfers, further emphasizing the need for staff-initiated interventions. Medical records indicated the resident was admitted with moderate protein-calorie malnutrition and a Stage IV pressure ulcer of the left buttock, and the most recent wound care note documented the need for preventative measures such as heel protectors or pillows and regular repositioning. Despite these documented interventions, observations revealed that the resident's heels were not consistently offloaded and that positioning devices were not always in use. Interviews with the unit manager confirmed the expectation for frequent repositioning and heel elevation, but these interventions were not consistently observed in practice.