Failure to Prevent Pressure Ulcer Due to Inadequate Bed Accommodation
Penalty
Summary
A deficiency was identified when the facility failed to provide an environment conducive to the healing of a pressure ulcer for one resident. The resident, who had chronic kidney disease, diabetes, and depression, was readmitted to the facility and was able to communicate their needs. Multiple observations showed the resident's feet consistently pressed against the footboard of the bed due to their height, with a gap between the mattress and the footboard filled by a rolled-up blanket. The resident reported that their feet always touched the footboard, and staff confirmed the bed was not long enough for the resident's height. Provider orders required staff to ensure proper mattress function and body positioning, but these were not adequately followed. Interviews with facility staff revealed that the risk of pressure ulcer development from the resident's feet pressing against the footboard was not recognized or addressed in a timely manner. The Resident Care Manager and the Director of Nursing Services both acknowledged that this factor should have been considered in the investigation and incident report regarding the pressure ulcer. Interventions to prevent the resident's foot from pressing against the footboard were not implemented until after the issue was observed and brought to staff attention.