Failure to Provide Appropriate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries for three of five residents reviewed. One resident developed a facility-acquired suspected deep tissue injury (DTI) that was incorrectly staged after it progressed to include slough, and the recommended change in wound treatment was not implemented in a timely manner. The care plan was not updated to reflect changes in the wound, and staff continued to use the previous treatment despite new recommendations. Additionally, multiple observations showed that the resident’s heels were not floated as required by the care plan, and staff interviews revealed a lack of awareness regarding this intervention. Another resident, who was at risk for pressure injuries and had a history of heel ulcers, was observed with heels resting directly on the bed and not being floated, contrary to the care plan. Documentation of turning and repositioning was incomplete, with several shifts indicating that the resident was not repositioned as required. Staff interviews further indicated uncertainty about the interventions in place for pressure injury prevention. A third resident did not consistently receive pressure injury treatments as ordered during the review period. The facility’s own policy required regular assessment, accurate staging, and timely updates to care plans and interventions based on wound changes, but these standards were not met. Documentation and communication lapses, incorrect wound staging, and failure to implement or update care interventions contributed to the deficiencies identified by surveyors.