Failure to Update Pressure Ulcer Prevention Measures After Change in Risk Status
Penalty
Summary
The facility failed to implement appropriate preventative measures to prevent pressure ulcers for a resident identified as at risk. Upon admission, the resident had no open areas on her feet, and her initial Braden scale assessment indicated she was not at risk for pressure ulcer development. However, a subsequent Braden scale assessment showed a decreased score, indicating the resident was at risk for pressure ulcer development. Despite this change, the care plan was not updated to include new preventative interventions, and the only interventions in place were a preventative mattress and turn and reposition as needed. It was also noted that the mattress in use was not a specialty mattress. As a result of the lack of updated preventative measures, the resident developed a deep tissue injury (DTI) to her left heel, which was first noted as bleeding and bruising and later documented as a DTI with eschar. The facility did not initiate additional preventative interventions after the resident's risk status changed, leading to the development of the pressure ulcer. The deficiency was identified through clinical record review, observations, and staff interviews.