Failure to Reassess and Implement Pressure Ulcer Interventions for Resident Refusing Repositioning
Penalty
Summary
The facility failed to comprehensively reassess and update pressure ulcer interventions for a resident who was identified as refusing repositioning during overnight hours and subsequently developed a new pressure injury. The resident, who had a history of spinal cord dysfunction, hemiplegia, and hemiparesis following a stroke, was assessed as being at mild risk for pressure ulcers and required moderate assistance with bed mobility. The care plan included specific interventions such as scheduled repositioning every three hours at night, use of a specialty mattress, and verbal cues to encourage repositioning, but documentation and implementation of these interventions were inconsistent, particularly during the night shift when the resident preferred not to be disturbed. Staff interviews revealed that the resident often refused repositioning at night, preferring to sleep uninterrupted, and that these refusals were not consistently documented in the electronic medical record due to system limitations. Nursing assistants and nurses were aware of the resident's preferences and attempted to encourage repositioning, but there was no formal documentation of refusals or a risk versus benefit discussion regarding the resident's choices. The wound care nurse and other staff noted that after the pressure ulcer was identified, efforts to reposition the resident increased, but prior to the injury, there was a lack of comprehensive reassessment and adaptation of interventions in response to the resident's refusals. Family members were not informed of the resident's refusals to reposition, and the care plan did not reflect a risk versus benefit analysis or notification to the physician regarding the resident's choices. The facility's policy required comprehensive assessment and care planning with input from the interdisciplinary team and family, but this was not fully implemented in the case of this resident. As a result, the resident developed a deep tissue pressure injury that was discovered during a skin assessment, with staff attributing the injury to prolonged pressure during the night and possible contact with an object.