Failure to Prevent and Document Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to prevent the development of two Stage II pressure ulcers on the upper left shoulder of a resident who was at high risk due to immobility and recent right leg fractures. Observations showed the resident was frequently positioned in a reclining Broda chair, leaning to one side for extended periods without repositioning, and with contractures limiting mobility. The care plan for skin integrity had not been updated with new interventions following the development of the pressure ulcers, and preventive measures such as regular repositioning and pressure relief were not adequately implemented. Record reviews revealed that wound care for the left shoulder began after the ulcers were discovered, but there was a lack of documentation regarding wound measurements, photographs, and timely physician progress notes. The wounds were first noted as blisters, and there was no evidence of comprehensive assessment or communication with the physician about the new pressure injuries or the resident's recent fractures. The facility's own policy required regular assessment, use of pressure redistribution devices, and individualized repositioning, but these were not consistently followed. Interviews with nursing staff and the DON confirmed that wound measurements and documentation were only completed after the surveyor's observation, and there was no prior photographic or measurement record of the wounds. The lack of timely assessment, documentation, and implementation of preventive interventions contributed to the development and progression of the pressure ulcers, as well as the resident's pain and discomfort.