Failure to Consistently Assess Pressure Injuries and Maintain Pressure Redistribution Equipment
Penalty
Summary
The facility failed to ensure that pressure injuries (PIs) were consistently assessed and that ordered pressure redistribution equipment was in place and functional for a resident with multiple PIs. Upon admission, the resident was cognitively intact, required substantial to maximal assistance with bed mobility, was at risk for PI formation, and had two Stage 3 and one Stage 4 PIs. The resident had an order for a low air loss (LAL) mattress for pressure redistribution, but observations revealed that the mattress was not functioning properly, as indicated by red flashing lights for low pressure and power failure. The resident reported feeling the bed frame through the mattress since admission, requiring pillows for comfort, and staff did not notice or address the malfunction until several days later. In addition to equipment issues, the facility did not consistently assess or document the resident's pressure injuries. While the initial evaluation and hospital records documented unstageable PIs to both heels and other areas, subsequent wound care consults failed to mention or assess the right heel PI. Facility progress notes indicated ongoing wound care and dressing changes for both heels, but there was no documentation of measurements or assessments for the right heel PI after admission. The wound care company responsible for weekly assessments also did not document the right heel PI in their consults. Interviews with facility leadership confirmed that the resident was admitted with PIs to both heels, consistent with hospital records, and that facility staff documented heel wounds through several weeks. However, there was no evidence that the right heel PI was measured, assessed, or monitored after admission, despite ongoing wound care. This lack of consistent assessment and failure to ensure functional pressure redistribution equipment constituted the deficiency identified in the report.