Failure to Timely Implement Individualized Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement timely, individualized, and effective interventions for pressure ulcer care for one resident with significant risk factors and existing pressure ulcers. The resident was admitted with multiple diagnoses, including hemiplegia, contractures, incontinence, and existing pressure ulcers on both heels. Upon admission, assessments identified the resident as high risk for pressure injuries, and documentation showed the presence of unstageable and Stage III pressure ulcers with heavy drainage and necrotic tissue. The care plan included interventions such as pressure-relieving devices, nutritional supplements, moisture barriers, and assistance with mobility and hygiene. Despite these documented interventions, there were delays and inconsistencies in their implementation. The resident did not receive a low air loss mattress until eight days after admission, despite requesting it on the first day and being at high risk for further skin breakdown. The resident also reported that staff did not consistently assist with turning, repositioning, or offloading the heels unless specifically requested. Observations confirmed that the resident's heels were directly on the bed without protective boots, and interviews with staff verified that the boots were not in use at the time of observation. The resident and a family member both indicated that necessary equipment and interventions were only provided after complaints were made to external authorities. Further review of wound care notes showed that the pressure ulcers increased in size before eventually showing some improvement, and that debridement was delayed due to the resident's pain and refusal, with some interventions only initiated after repeated documentation of wound status. The facility's policy required assessment and documentation of risk factors and timely intervention, but the evidence indicated that these were not consistently or promptly followed, resulting in a failure to provide adequate pressure ulcer care and prevention.