Failure to Provide Comprehensive Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to develop and implement a comprehensive, effective, and individualized pressure ulcer prevention and treatment program for three residents, resulting in the development and worsening of pressure ulcers. One resident, who was morbidly obese, incontinent, and dependent on staff for bed mobility and toileting, developed a dark purple, non-blanchable suspected deep tissue injury to the right posterior thigh. This injury was attributed to the use of incontinence briefs that were too small and fastened tightly, despite physician orders for the brief to remain unfastened while in bed. Staff did not measure residents for appropriate brief sizes, and the largest available size was still inadequate. Documentation indicated that the order to leave the brief unfastened was signed as completed, but observations and interviews revealed that staff routinely fastened the brief, contributing to ongoing skin breakdown and pain for the resident. Another resident, who was cognitively impaired, developed an unstageable pressure ulcer to the right buttock. The initial wound was identified as an abrasion, but it progressed to an unstageable ulcer without evidence of individualized or effective interventions to prevent its development. Although a wound care nurse practitioner recommended a specific treatment regimen, there was a delay in ordering and implementing the treatment, and staff continued to apply the previous, less appropriate treatment. Additionally, there were multiple documented instances where the prescribed wound care was not completed as ordered. A third resident with paraplegia and obesity had multiple pressure ulcers, including a Stage IV ulcer and new suspected deep tissue injuries. The resident's care plan included wound treatments and preventative interventions, but there were issues with the availability of necessary wound care supplies. On at least one occasion, the required Triad cream was not available, and an alternative treatment was used instead, despite documentation indicating the prescribed treatment was completed. Staff interviews confirmed frequent shortages of wound care supplies and inconsistent ordering practices, leading to lapses in appropriate wound care.