Failure to Provide Comprehensive Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide comprehensive and individualized pressure ulcer care and prevention for two residents with a history or risk of pressure ulcers. For one resident admitted with multiple fractures, osteoporosis, and a surgical wound, documentation revealed the presence of a pressure ulcer to the coccyx upon admission. However, there was no detailed description or measurement of the area in the initial care plan, and no treatment was documented until several days after admission, following evaluation by a wound physician. Although a low air loss mattress was recommended for this resident, there was no physician order for it, and observations confirmed that the mattress was never provided during the relevant period. For another resident with diagnoses including atrial fibrillation, malnutrition, and bone density disorders, a physician order for a low air loss mattress was in place, and the care plan included interventions for skin integrity. Despite this, documentation showed that after a resolved Stage III pressure ulcer, the resident developed new open areas to the coccyx, which were not promptly documented or treated. There was a delay of several days between the identification of the open areas and the implementation of wound care treatment. Additionally, the low air loss mattress in use was found to be malfunctioning and set for an incorrect weight, which was not addressed until after surveyor intervention. Policy review indicated that thorough skin assessments were required upon admission, weekly, and with any significant change, and that staff were to document and notify physicians of any skin concerns. The facility did not consistently follow these procedures, as evidenced by incomplete documentation, delayed treatment, and failure to implement recommended interventions for pressure ulcer prevention and care.