Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to assess, monitor, and implement a comprehensive and individualized pressure ulcer prevention program for two residents, resulting in the development and inadequate management of pressure ulcers. One resident, who was dependent on staff for bed mobility and used a wheelchair, was admitted without skin issues but was identified as at risk for skin breakdown. Despite care plans and physician orders for preventive measures such as floating heels and regular repositioning, the resident developed an unstageable pressure ulcer on the left heel. The ulcer was not discovered until it had progressed significantly, and there was no evidence of timely intervention, assessment, or notification to the physician at the time of discovery. The facility did not implement appropriate offloading interventions or wound care until several days after the ulcer was identified. Another resident was admitted with multiple complex medical conditions, including end-stage renal disease and an unstageable pressure ulcer to the sacrum and right heel, as documented in the hospital discharge summary. However, the facility's admission assessment failed to identify these skin issues, and the resident was not comprehensively assessed for pressure ulcers upon admission. There was a delay of two days before any wound treatment was initiated, and the required comprehensive wound assessment and documentation were not completed as per facility policy. Both cases demonstrate a lack of timely and thorough skin assessments, failure to implement and document individualized interventions, and delays in initiating appropriate wound care. The facility's actions did not align with its own wound care policy, which requires prompt assessment, documentation, and intervention for residents at risk of or presenting with pressure ulcers. These deficiencies resulted in actual harm to at least one resident and affected two out of three residents reviewed for pressure ulcers.