Failure to Assess, Care Plan, and Prevent Pressure Injuries Leads to Immediate Jeopardy
Penalty
Summary
Surveyors identified that the facility failed to ensure comprehensive assessment, care planning, and implementation of interventions to prevent and treat pressure injuries for multiple residents. Several residents with significant comorbidities, such as diabetes, heart failure, immobility, and cognitive impairment, were at risk for pressure injuries or developed new wounds while in the facility. In multiple cases, when new wounds or pressure injuries were discovered, there was no evidence of timely or comprehensive assessment, staging, or documentation. For example, one resident developed a pressure injury to the left buttock and a blood blister to the right great toe, but the medical record lacked a comprehensive assessment, and the care plan was not updated to reflect these new wounds or interventions to promote healing. Additionally, treatments were sometimes performed by unlicensed staff, and documentation of wound care was inconsistent or incomplete. Another resident with a history of hemiplegia, diabetes, and impaired mobility developed multiple pressure injuries, including a deep tissue injury (DTI) to the left medial foot and additional DTIs to the left lateral foot and fifth toe. The care plan was not updated to address the resident's specific positioning challenges, such as outward rotation of the left leg, and interventions like heel offloading were not consistently implemented or documented. Observations revealed that pressure-relieving devices were not always in use, and staff were sometimes unaware of new wounds. Comprehensive assessments and care plan updates were delayed or missing, and the facility did not ensure that all wounds were properly identified, staged, and treated according to standards of practice. In another case, a resident with severe cognitive impairment and total dependence for mobility developed a large intact blister on the left heel, later identified as a DTI. There was a delay of several days before a comprehensive assessment was completed, and wound measurements did not include depth until much later. The care plan was not promptly revised to reflect the new pressure injury or to implement additional preventive measures. Across multiple cases, surveyors found that the facility did not consistently perform or document comprehensive skin assessments, update care plans, or ensure that interventions were in place and followed, resulting in the development and worsening of pressure injuries. These failures led to a finding of immediate jeopardy, particularly in the case of a resident who developed a facility-acquired, avoidable stage 4 pressure injury with osteomyelitis.