Failure to Prevent and Properly Manage Pressure Ulcers
Penalty
Summary
The facility failed to follow its own wound care and pressure ulcer prevention protocols for two residents at high risk for pressure ulcers. One resident, who was incontinent, immobile, and receiving hospice care, developed a new Stage II pressure ulcer on the right buttock. Despite care plan interventions requiring frequent incontinence checks, prompt perineal care, and regular repositioning, observations showed the resident remained seated on their buttocks in a wheelchair for extended periods without repositioning or incontinence care. Staff interviews confirmed that the resident was not repositioned or checked for incontinence at least every two hours as required, and the lack of these interventions was acknowledged as a contributing factor to the development of the new pressure ulcer. Another resident, who was cognitively intact but dependent on staff for mobility and personal care, had an existing Stage IV pressure ulcer on the sacrum. The care plan required frequent repositioning, keeping the resident clean and dry, and proper wound care. However, observations revealed the resident was left lying flat on their back for prolonged periods, with no positioning devices used to offload pressure from the wound area. The resident was also found with a heavily soiled brief and dirty absorbent pads, and perineal care was not performed as frequently as required. Wound care was administered, but the dressing was not always properly secured, and fecal matter was found on and around the wound dressing, increasing the risk of infection and delayed healing. Staff interviews, including those with CNAs, LPNs, the wound nurse, and the DON, consistently indicated an expectation for residents at risk for pressure ulcers to be repositioned and checked for incontinence at least every two hours. Despite these expectations and facility policy, direct care observations and staff admissions demonstrated that these standards were not met for the two residents in question, resulting in the development of a new pressure ulcer for one resident and inadequate care for an existing Stage IV ulcer in another.