Failure to Provide Timely and Comprehensive Pressure Injury Assessment and Prevention
Penalty
Summary
Multiple deficiencies were identified in the facility's management of pressure injuries for several residents. In one case, a resident was admitted with a history of vertebral fractures, chronic kidney disease, heart failure, morbid obesity, and visual impairment. The hospital discharge summary indicated the presence of pressure injuries, but upon admission, only a Licensed Practical Nurse performed the initial skin assessment, noting abrasions and bruising. A comprehensive assessment by a Registered Nurse did not occur until five days later, despite the resident having two unstageable pressure injuries. Observations revealed that the resident's heels were not being offloaded as required, and the air mattress was set incorrectly for the resident's weight. Staff did not consistently communicate or implement offloading interventions, and there was a lack of timely and thorough wound assessment and documentation. Another resident with dementia, malnutrition, and spinal stenosis, who was also receiving hospice care, developed an open area on the right buttock. The hospice aide documented the wound, but no nursing assessment was completed for a week. The care plan included interventions such as offloading heels and using an alternating pressure mattress, but repeated observations showed the resident's heels were not being offloaded. There was also confusion and inconsistency in wound care documentation and dressing application, with a deep tissue injury on the sacrum being discovered without prior documentation or physician orders. The resident's care plan did not reflect refusals of care, despite documentation of resistance to repositioning and treatments. A third resident was admitted with a stage 4 sacral wound, but the initial admission assessment lacked a comprehensive description of the wound, including staging, wound bed, and surrounding tissue. The first detailed assessment was not completed until five days after admission by the wound doctor. Facility staff, including the wound nurse and unit manager, acknowledged that a comprehensive assessment should have been completed upon admission. Across all cases, the facility failed to ensure prompt and thorough assessment, documentation, and implementation of pressure injury prevention and management interventions, as required by their own policy and professional standards of practice.