Failure to Provide Timely Pressure Ulcer Assessment and Prevention
Penalty
Summary
The facility failed to provide timely assessment, monitoring, and interventions to prevent the development of a pressure ulcer in a resident who was assessed at moderate risk for pressure ulcer development. The resident was admitted with multiple complex medical conditions, including a stage four sacral pressure ulcer, diabetes mellitus type II, congestive heart failure, and vascular ulcers. The care plan included interventions such as skin checks each shift, offloading of heels, use of heel suspension boots, and pressure redistribution mattresses. However, there was no documented evidence that skin checks were completed each shift as required by the care plan. Despite the presence of heel protector boots, the resident developed a new, in-house acquired unstageable pressure ulcer on the left lateral heel. The wound was first noted as a blister and later progressed to a stage three pressure ulcer requiring surgical debridement and ongoing wound care. There was no documentation of ongoing assessments to determine the causative factors of the wound or to evaluate the need for changes in pressure reduction interventions. Staff interviews confirmed that no further evaluation occurred to determine the origin of the wound, and there was no evidence that the skin under the offloading boots was assessed each shift. The Director of Nursing confirmed that the required skin assessments were not documented, and the resident was not assessed as high risk for pressure ulcer development despite significant risk factors and existing wounds. The facility's clinical protocol required monitoring and physician guidance when wounds were not healing or new wounds developed, but this was not followed in the case of this resident.