Failure to Implement and Document Pressure Ulcer Prevention and Care
Penalty
Summary
A resident with dementia and muscle weakness was admitted to the facility and had physician orders for the use of pressure prevention devices, frequent turning and repositioning, and offloading of heels while in bed. Despite these orders, documentation revealed that the resident was not enrolled in a turning and repositioning program, and was totally dependent on staff for bed mobility. The care plan identified a risk for skin integrity issues related to incontinence, but there was no evidence of a care plan specifically addressing a facility-acquired pressure ulcer after one was identified. Clinical records showed that an open area was discovered on the resident's sacrum by a CNA and reported to the charge nurse, who assessed and measured the wound. A wound physician later documented significant deterioration of the wound, with necrosis and unmeasurable depth, and recommended offloading and repositioning per protocol. However, there was no documented evidence that a care plan was initiated for the pressure ulcer, and the Director of Nursing confirmed this omission. Additionally, some wound consult documentation was unavailable due to a system changeover.