Failure to Provide Pressure Ulcer Prevention and Repositioning
Penalty
Summary
A resident with a history of diabetes, stroke, and decreased mobility in all limbs was admitted to the facility and assessed as being at moderate risk for pressure injury development, as indicated by a Braden Scale score of 14. The resident required total staff assistance for bed mobility, transfers, and positioning, and was incontinent of bowel and bladder. Despite these risk factors and documentation of redness in the peri area and buttocks, the resident did not have a pressure injury at admission. However, 24 days after being identified as at moderate risk, the resident developed a facility-acquired Stage II pressure injury on the coccyx. At the time of the injury, no pressure-relieving device, such as an air mattress, was observed on the resident's bed. Observations on the day following the injury revealed the resident lying on her back in bed without any pressure-reducing device. Later, the resident was observed in a partially reclined wheelchair for several hours without being repositioned or offered bathroom assistance by staff, as confirmed by both direct observation and the resident's representative. These findings indicate that the facility failed to provide necessary pressure-reducing measures and regular repositioning, which contributed to the development of the pressure injury.