Failure to Implement and Monitor Pressure Ulcer Prevention and Care
Penalty
Summary
Facility staff failed to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and wound care for a resident who was at risk and had a history of pressure ulcers. The resident, who was cognitively intact and required extensive assistance with bathing and dressing, was admitted with a stage 2 pressure ulcer on the right heel. The care plan identified risk factors such as impaired mobility, edema, fragile skin, diabetes, and lymphedema, but did not include specific interventions for pressure redistribution or pressure ulcer prevention. Despite the resident's ongoing risk and the presence of an unhealed pressure ulcer, the care plan lacked measures to prevent further skin breakdown. Subsequent documentation showed the development of a new pressure ulcer and a deep tissue injury on the right heel, with the wound worsening over time and becoming open, weeping, and foul-smelling. There were no physician orders or documented treatments for the pressure ulcer, and the wound nurse confirmed that interventions were not reviewed or modified as the wound deteriorated. Observations confirmed the presence of a significant wound with a foul odor, and facility policy requiring ongoing evaluation and intervention for pressure injury risk was not followed.