Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A resident identified as at risk for pressure ulcers developed a pressure ulcer on her spinal area due to the facility's failure to implement and maintain appropriate pressure ulcer prevention interventions. The resident, who had moderate cognitive impairment and was underweight with a BMI of 17, was dependent on staff for activities of daily living and had a history of limited mobility. Physician orders and the care plan included the use of a pressure-relieving mattress, a pressure-relieving cushion in her wheelchair, frequent repositioning, offloading of heels, and weekly skin assessments. However, observations revealed that the resident did not have a specialized mattress on her bed, and the sacral dish cushion intended for her wheelchair was not in use. Staff interviews confirmed a lack of awareness and implementation of these interventions, with some staff unaware of the need for the sacral dish cushion and others noting its removal without replacement. The resident's care plan and kardex specified interventions such as the use of assist bars for repositioning, education on offloading pressure, and the use of specific cushions for pressure relief. Despite these documented interventions, staff reported that the resident was often noncompliant with repositioning and the use of wedges, preferring to lie on her back. The Prevalon boots, intended to offload heel pressure, were only recently implemented, and the specialized mattress was not present at the time of the pressure ulcer's development. Additionally, there was a lack of communication and follow-through regarding the removal of the sacral dish cushion by therapy, with no alternative pressure-relieving measures put in place. The facility's Nursing Skin Care Protocol required comprehensive assessment, documentation, and communication regarding skin issues, including notification of the dietary manager and registered dietician for nutritional assessment. However, the dietician's progress notes did not address the resident's skin condition or risk for pressure ulcers, and the protocol itself was found to be outdated and not reflective of current practices. The DON was not aware that staff were no longer using the sacral dish cushion, and there was no evidence that the required interventions were consistently implemented or monitored prior to the development of the pressure ulcer.