Failure to Provide Timely and Effective Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide adequate and effective pressure ulcer prevention and care for three residents, resulting in the development and worsening of pressure ulcers. One resident with a pressure ulcer on the left heel did not receive wound care as ordered, as observed during a wound care session where no dressing or treatment was present and the area had a large amount of dried, crusted debris. The wound nurse practitioner confirmed that the prescribed daily wound care had not been completed, and the facility's policy requiring ongoing evaluation and documentation of skin changes and interventions was not followed. Another resident, who was cognitively impaired and dependent on staff for activities of daily living, developed a pressure ulcer on the buttocks due to prolonged sitting without adequate repositioning. The care plan did not reflect the presence of a Stage III pressure ulcer, and interventions were not updated. Weekly skin assessments were missed, and wound care orders were not consistently implemented, as evidenced by the absence of dressings during observations. The resident was also found without required heel boots and on a malfunctioning air mattress, with staff confirming these lapses in care. A third resident, also cognitively impaired and at high risk for pressure ulcers, did not have an air mattress in place as ordered for prevention. Weekly skin assessments were not completed as scheduled, and documentation of skin integrity was inconsistent and sometimes inaccurate. The resident developed a deep tissue injury that progressed to a Stage III and then to an unstageable pressure ulcer, with repeated observations showing that wound treatments were not in place as ordered. Communication failures between facility staff and hospice care further contributed to the lack of appropriate interventions and monitoring.