Failure to Implement Pressure Ulcer Prevention and Management Interventions
Penalty
Summary
A deficiency occurred when a resident, who was at risk for pressure ulcers due to diagnoses including schizophrenia, depression, and severe obesity, developed a sacral wound that progressed from a Stage 3 to an unstageable pressure ulcer. Despite being identified as at risk and having a care plan in place, there was no documented evidence that interventions such as offloading, an incontinence schedule, or appropriate incontinence care were implemented to prevent further deterioration of the wound. The resident was incontinent of bladder and frequently incontinent of bowel, yet the care plan did not address incontinence management, and staff failed to document or implement necessary interventions. Physician wound assessments repeatedly noted the need for pressure offloading and incontinence management, but these recommendations were not consistently acted upon or documented by nursing staff. The resident continued to use a standard foam wheelchair cushion, which was not appropriate for a Stage 3 or unstageable pressure ulcer, and a pressure-relieving cushion was not provided until much later. Interviews with staff revealed a lack of communication and follow-through regarding the need for specialized equipment and interventions, with the rehabilitation department not being notified in a timely manner and nursing staff not updating care plans or implementing recommended protocols. Observations and interviews confirmed that the resident's wound worsened over time, with increasing necrotic tissue and delayed healing, and that appropriate interventions were not put in place until after significant deterioration had occurred. The facility's own policies required regular monitoring, pressure relief, and incontinence management for residents at risk, but these were not followed or documented for this resident, resulting in actual harm.