Failure to Implement and Document Pressure Ulcer Prevention for Dependent Resident
Penalty
Summary
A resident with diagnoses including dementia and chronic kidney disease, who was totally dependent on staff for bed mobility, was identified as being at high risk for pressure ulcers. The resident's care plan noted risk factors such as impaired mobility and incontinence, but there was no documented evidence that staff implemented or documented regular turning and repositioning interventions. Nursing notes indicated the development of redness on the sacrum, which progressed to an open area with slough and mild erythema, later assessed as end-stage skin failure with a full-thickness wound. Despite physician orders for offloading the heels every shift, observations and staff interviews confirmed that the resident's heels were not consistently offloaded, and there was no evidence of a turning and repositioning schedule or documentation of these interventions. Staff interviews revealed that there was no set schedule or documentation process for turning and repositioning the resident, and the facility lacked a policy for residents requiring total assistance. The DON confirmed that all residents were expected to be turned every two hours, but there was no documentation to support this for the resident in question. Observations further confirmed that the resident's heels were not offloaded as ordered, and the care plan did not include this intervention. These failures resulted in the development and progression of a pressure ulcer for a resident at high risk.