Failure to Consistently Document and Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions to promote pressure ulcer healing were consistently implemented for a resident with multiple pressure ulcers. Facility policies required turning and repositioning of residents at risk for pressure ulcers at least every two to three hours, with documentation of these interventions. Wound care provider notes specified that the resident should be turned every two hours using a foam wedge. However, review of the resident's ADL records over several months revealed numerous undocumented opportunities for turning and repositioning, with significant numbers of blanks in the records for this task. The resident's care plan also indicated the need for staff assistance with transfers and repositioning due to severe mobility limitations. Interviews with staff confirmed that the resident was immobile, contracted, and unable to turn independently, requiring substantial assistance. Staff reported that the resident was sometimes resistive to turning due to discomfort, and repositioning was attempted as much as the resident would allow. Despite these efforts, the Director of Nursing acknowledged that, due to the incomplete documentation, there was no way to verify that the resident was turned every two hours as required. The resident had multiple stage three and four pressure ulcers and deep tissue injuries, all present upon admission, and required ongoing wound care interventions.