Failure to Implement Timely Pressure Ulcer Prevention and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to assess, monitor, and implement pressure-relieving interventions for a resident who developed an unstageable pressure ulcer to the coccyx area. The resident was admitted with a history of stroke, impaired mobility, and skin fragility, but was initially assessed as being at low to moderate risk for pressure ulcers, with no pressure injuries present on admission. Despite the presence of risk factors such as immobility, poor nutritional intake, and incontinence, the care plan did not include comprehensive pressure ulcer prevention measures until after a red area was discovered on the coccyx. When a red area was first noted on the resident's coccyx, there was a delay in both assessment and the implementation of preventative interventions. Documentation and interviews revealed that no interventions to prevent further skin breakdown were put in place between the initial discovery of the red area and the subsequent assessment, during which the wound had already opened. The facility's own policy required immediate preventative measures and individualized repositioning plans for residents unable to reposition themselves, but these were not initiated in a timely manner. Additionally, there was a lack of consistent wound assessment and documentation, with significant gaps between assessments and no evidence of a repositioning assessment being completed. As the resident's condition deteriorated, the pressure ulcer progressed to an unstageable wound with necrotic tissue and infection, ultimately requiring hospitalization for cellulitis and advanced wound care. Interviews with staff and providers confirmed that preventative measures were not implemented promptly after the initial signs of skin breakdown, and that the severity of the wound could have been mitigated with earlier intervention. The facility's failure to follow its own protocols for pressure ulcer prevention and timely intervention directly contributed to the development and worsening of the resident's pressure ulcer.