Failure to Implement Timely Pressure Ulcer Prevention and Intervention
Penalty
Summary
The facility failed to adequately identify and implement pressure ulcer prevention interventions for two residents who were at risk for developing pressure ulcers. One resident, who was non-ambulatory and had severe cognitive impairment, developed a pressure ulcer on her heel. Prior to the ulcer's identification, the resident had complained of heel pain, but heel protectors were not provided until after the skin breakdown was noted. Documentation showed that interventions such as heel boots and an air mattress were only added to the care plan after the ulcer developed. Additionally, there was no documentation that the resident’s representative was notified of the change in her condition, and the wound nurse included interventions in the clinical review that were not in place prior to the ulcer’s development. Another resident, who had a history of pressure ulcers and was at moderate risk according to the Braden Scale, developed a new pressure ulcer on her coccyx. Observations revealed that her heel boots were not in use as required, and she was often found lying on her back despite having a pressure ulcer in that area. The care plan indicated she needed a pressure-reducing mattress, but she was observed with a standard mattress. Staff interviews confirmed that repositioning was not performed as frequently as required, and documentation showed the resident was only repositioned one to three times per day, rather than every two to three hours as expected. The resident herself reported that staff did not reposition her and that she would have preferred more frequent repositioning. The facility’s own policy required timely risk assessments, implementation of individualized interventions, and prompt notification of changes in skin condition to the physician and resident representative. However, in both cases, interventions were either delayed or not implemented as planned, and documentation was incomplete or inaccurate. The clinical reviews to determine whether the ulcers were avoidable were not completed within the expected timeframe, and in one case, the review was left blank until after the deficiency was identified.