Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
Facility staff failed to prevent the development of a pressure ulcer and did not provide appropriate management for an avoidable pressure ulcer in one resident. The resident, who had significant cognitive impairment and multiple medical conditions including chronic non-occlusive DVT and congestive heart failure, was admitted after a hospital stay. Initial assessments indicated intact skin, but a sacral pressure ulcer was identified within eleven days of admission. The care plan noted the resident was at risk for impaired skin integrity but did not address the newly developed sacral ulcer after it was identified. Documentation of the pressure ulcer's progression was incomplete, with missing weekly skin observation tools and lack of detailed information such as measurements, stage, and characteristics for several weeks. Staff interviews confirmed that required weekly skin assessments were not consistently performed or documented. The resident reported ongoing discomfort from the ulcer, and direct observation confirmed the presence of a stage two sacral pressure ulcer. The deficiency was due to the facility's failure to consistently assess, document, and update the care plan to address the resident's pressure ulcer after its development.