Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure ulcers for two residents. One resident was observed with a wound dressing on her right heel but had an open area on her coccyx without a dressing during morning care. Staff applied only a moisture barrier cream and a new incontinence brief, and the resident expressed pain when moved. Nursing progress notes indicated a history of bruising and the development of a pressure ulcer on the coccyx, which progressed to an unstageable ulcer and later a Stage III ulcer with maceration. The wound nurse was reportedly seeing the resident weekly, but dressing changes were otherwise performed by staff. Another resident was repeatedly observed lying on his back in bed with the head of the bed elevated, and his head tilted forward to the left side, with a neck pillow/collar not in use as care planned. Observations over multiple days showed the resident remained in the same position for extended periods, and staff interviews confirmed that turning and repositioning were not consistently performed every two hours as required. The resident had a history of pressure injuries and maceration on his ear and neck due to positioning and moisture, and current assessments revealed multiple pressure wounds on the buttocks, including Stage I and Stage II ulcers. The care plan specified the use of a soft cervical collar-type pillow and routine repositioning, but these interventions were not consistently implemented. Documentation and wound tracking for both residents showed ongoing issues with pressure ulcer management, including incomplete wound documentation, inconsistent use of preventive devices, and lack of adherence to turning and repositioning protocols. These failures contributed to the development and chronicity of Stage II and Stage III pressure ulcers in both residents, as evidenced by direct observation, staff interviews, and record review.