Failure to Prevent and Manage Pressure Injuries Due to Inconsistent Implementation and Documentation
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services to prevent the development and worsening of pressure injuries (PIs) and to promote healing, as evidenced by the care of three residents. One resident with multiple comorbidities, including dementia, diabetes, and chronic kidney disease, developed an unstageable pressure injury to the right heel. Despite being care planned for bilateral heel boots at all times and regular turning and repositioning, documentation showed inconsistent implementation of these interventions. The resident was observed without required offloading boots while seated in a Broda chair, and staff interviews confirmed a lack of awareness and adherence to the care plan. Additionally, turning and repositioning were not consistently documented, and the facility did not have a policy for this intervention at the time of the deficiency. Another resident, admitted with a pressure injury on the coccyx and identified as at risk for further pressure injuries, developed an unstageable pressure injury on the left heel. The care plan required Prevalon boots at all times except during therapy, but the resident was observed without the boots and with heels in direct contact with the mattress. The Medication Administration Record and Kardex did not reflect the intervention, and staff were unaware of the requirement, indicating a breakdown in communication and care planning. A third resident did not receive a timely assessment of a pressure injury, with five days elapsing before the wound was evaluated. Facility policies required accurate and timely assessment and documentation of pressure injuries, including measurements and wound characteristics, but these were not followed. The deficiencies were substantiated by direct observations, record reviews, and staff interviews, which revealed lapses in implementing and documenting evidence-based interventions for pressure injury prevention and management.