Failure to Prevent Development of Pressure Ulcers in At-Risk Residents
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in two residents who were at risk due to their medical conditions. One resident, admitted with multiple diagnoses including Alzheimer's disease, diabetes, obesity, and peripheral vascular disease, did not have adequate interventions in place prior to developing a pressure ulcer on the right trochanter. The only documented preventive measure was the use of a pressure-reducing mattress and wheelchair cushion. The wound was first identified by nursing staff and later assessed by the wound nurse, who could not specify what interventions were in place before the ulcer developed. No root cause analysis was documented in the medical record, and the Director of Nursing acknowledged that the ulcer was avoidable and that additional interventions, such as an air mattress, should have been implemented earlier. Another resident, admitted with a history of fractures, cerebral palsy, developmental disorder, and severe cognitive impairment, developed a deep tissue injury to the right heel. Prior to the injury, the only intervention listed was to elevate the heels off the bed surface while at rest. The wound was documented and treated after it was discovered, but there was no evidence of a root cause analysis being performed. The Director of Nursing stated that the injury was avoidable and that more interventions should have been in place given the resident's risk factors and medical history. In both cases, the facility did not implement comprehensive preventive measures or conduct timely root cause analyses after the pressure ulcers developed. The lack of documented interventions and failure to update care plans contributed to the development of avoidable pressure ulcers in residents with significant risk factors. Observations confirmed that wound care was provided after the ulcers were identified, but preventive actions were insufficient prior to their occurrence.