Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and treatment to prevent and heal pressure injuries for two residents who were at risk or had existing pressure injuries. For one resident with multiple comorbidities including diabetes, ESRD, and mobility impairment, there was a lack of documentation and implementation of physician-ordered interventions such as floating heels and use of heel boots. Despite orders in place, the Treatment Administration Record (TAR) did not reflect that these interventions were carried out, and the care plan was not updated in a timely manner to include necessary devices like bed extenders. The resident developed a deep tissue injury (DTI) to the right heel, and there were inconsistencies and omissions in wound documentation and descriptions. Interviews with staff indicated confusion regarding the cause of the wound and the application of appropriate interventions, with some staff attributing the injury to the resident's foot being against the footboard and others to underlying medical conditions. Observations confirmed that interventions were not consistently in place, and the resident reported inconsistent use of protective devices. Another resident, admitted without pressure injuries but assessed as at moderate and later very high risk for developing them, did not have new care plan interventions initiated after risk increased. Although there was a physician order to float heels, there was no documentation that this was done prior to the development of a Stage 1 pressure injury, which progressed to a DTI. Staff interviews confirmed that heel boots were not in use before the injury was identified, and documentation supported that interventions were only implemented after the pressure injury was found. The resident also experienced significant weight loss and poor oral intake, with delayed initiation of nutritional supplementation despite dietary recommendations. The care plan and TAR did not reflect timely or adequate implementation of preventive measures or documentation of compliance with interventions. The facility's own policy requires individualized, evidence-based interventions for residents at risk for pressure injuries, including implementation and documentation of physician orders, regular skin assessments, and timely updates to care plans. In both cases, the facility did not follow its policy regarding prevention, documentation, and timely intervention for pressure injuries. The lack of consistent documentation, delayed implementation of preventive devices, and failure to update care plans contributed to the development and progression of pressure injuries in these residents.