Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure injuries for a resident with significant risk factors. The resident, who was admitted with severe dementia, protein-calorie malnutrition, reduced mobility, and heart disease, required maximum assistance for bed mobility and transfers and had a high risk for pressure injuries as indicated by a Braden Scale score of 11. Upon admission, the resident had no pressure injuries, but subsequently developed a fluid-filled blister on the left heel and a pressure injury with slough and eschar on the right lateral malleolus. Observations and record reviews revealed that the facility did not consistently implement or document required interventions. The resident was observed multiple times without pressure-relieving devices, such as a pressure-relieving mattress or heel protectors, and their heels were not floated as ordered. Nursing notes indicated that interventions such as floating the heels and applying heel protectors were ordered, but these were not consistently carried out or documented. Additionally, required skin assessments were not completed or documented on several occasions as indicated in the Treatment Administration Records. Further, the resident's care plan did not reflect the development of the pressure injuries or include interventions to prevent new injuries or worsening of existing ones. Staff interviews and observations confirmed improper application of devices intended to relieve pressure, and the Director of Nursing acknowledged that staff needed more education on proper techniques. These failures resulted in the resident developing and experiencing worsening pressure injuries.