Failure to Implement Pressure Ulcer Prevention Policy Resulting in Pressure Injury
Penalty
Summary
The facility failed to implement its policy and procedure for pressure ulcer prevention for one resident, resulting in the development of a pressure injury on the coccyx area. Multiple interviews and record reviews revealed that required weekly skin assessments were not completed or documented, including on the weekly summary and shower sheets. Both the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) confirmed that skin assessments were missing for several dates, and there was no documentation of interventions such as repositioning for a resident identified as being at risk for pressure injuries. The resident in question had a history of being at moderate risk for pressure injuries, as indicated by a Braden score of 17, and was noted to be chairfast, very moist, and requiring partial to moderate assistance with mobility and hygiene. Despite these risk factors, there was no evidence that the care plan addressed necessary interventions such as moisture control, pressure reduction, or repositioning. Additionally, there was no documentation that the resident received education on the causes and prevention of pressure injuries. When an open wound was eventually discovered on the resident's buttocks, there was no wound assessment, measurement, or wound monitoring record completed, and no treatment order was initiated. The facility's policy required immediate implementation of a wound monitoring record and care plan revision upon identification of a wound, but these steps were not taken. The resident was later admitted to the hospital with an unstageable pressure injury, further confirming the lack of appropriate preventive and responsive care.