Failure to Prevent and Manage Pressure Ulcers Resulting in Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to ensure that the facility provided treatment and services consistent with professional standards of practice to prevent and manage pressure ulcers. Multiple residents developed new pressure ulcers or experienced worsening of existing wounds due to the facility's failure to implement physician and wound care practitioner recommendations, such as providing wound care, using air mattresses, and ensuring regular turning and repositioning. Facility documentation lacked evidence that these interventions were provided as ordered, and observations confirmed that required equipment, such as air mattresses and heel boots, were not in use for affected residents. Residents with significant medical needs, including those dependent on tracheostomy/ventilator and at high risk for pressure ulcers, did not have comprehensive care plans addressing necessary interventions like offloading, air mattresses, or turning and repositioning. The facility also failed to update or implement wound care orders as recommended by the wound care practitioner, resulting in the deterioration of wounds for several residents. In some cases, wounds progressed in size and severity, with documentation showing increases in wound dimensions, the development of drainage, slough, eschar, and wound odor. Interviews with the DON and Administrator confirmed that the facility did not follow professional standards or its own wound care guidelines. The DON acknowledged that staff failed to document and provide required interventions, and that care plans were incomplete for residents at high risk of pressure injuries. The facility's non-compliance with physician orders and lack of appropriate wound care led to actual harm for multiple residents and resulted in an Immediate Jeopardy situation.