Failure to Reassess and Update Interventions After Pressure Ulcer Development
Penalty
Summary
The facility failed to comprehensively reassess a resident after the development of an in-house acquired pressure ulcer, resulting in a lack of additional or modified interventions to promote healing and prevent complications. The resident, who had significant cognitive impairment, hallucinations, and care rejection behaviors, was identified as being at risk for pressure ulcers but had no ulcers at the time of the last formal assessment. Despite the development of a sacral pressure ulcer, documentation showed that the care plan and interventions remained largely unchanged, with staff continuing previous repositioning routines and applying various topical treatments without a documented comprehensive review. Observations and interviews revealed that staff were unsure of any new or additional interventions beyond the use of an air mattress and topical creams. There was inconsistency in wound care products used, and staff could not articulate a clear plan for wound management or prevention of further injury. The resident's nutritional status was not reassessed or addressed, despite wound care notes recommending optimization of nutrition. The medical record lacked evidence of interdisciplinary team involvement or a comprehensive evaluation of the resident's risk factors and needs after the ulcer developed. Interviews with nursing and hospice staff confirmed that no comprehensive reassessment or interdisciplinary review was conducted following the onset of the pressure ulcer. The assistant director of nursing acknowledged that such reviews were not routinely performed for pressure ulcer development and that documentation of interventions and risk reassessment was lacking. The facility's own policy required reassessment upon changes in condition, but this was not followed in the case of the resident who developed the pressure ulcer.