Failure to Follow Care Plan for Skin Integrity and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide care in accordance with a resident's care plan for non-pressure related skin concerns. The resident had cognitive impairment, required substantial to maximal assistance with most ADLs, and was at risk for pressure ulcers and skin alterations due to incontinence and a history of skin issues. The care plan included interventions such as applying barrier cream after each incontinent episode, encouraging cleansing and drying of skin folds, using heel protectors while in bed, floating heels with pillows, turning and repositioning every two to three hours, and using geri-sleeves or long sleeves to prevent skin tears and bruises. Physician orders also specified the use of geri-sleeves or long sleeves during the day and removal at bedtime. Observations revealed that the resident was not consistently provided with the required interventions. The resident was seen in short sleeves without geri-sleeves on multiple occasions, and her heels were not floated or protected as directed in the care plan. Nursing assistants and a registered nurse confirmed that these interventions were not implemented, and staff were unaware of the need for certain care plan elements, such as heel protectors and arm coverings. Facility leadership confirmed the importance of these interventions and the expectation that staff follow the care plan, but the required care was not provided as documented.