Failure to Provide Pressure Relieving Devices and Repositioning for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that two residents at risk for pressure ulcers received care consistent with professional standards of practice to prevent the development and worsening of pressure ulcers. Both residents had significant medical histories, including cognitive impairment, immobility, and existing pressure ulcers upon admission. Despite care plans indicating the need for frequent repositioning and the use of pressure-relieving devices, observations revealed that both residents were found lying on their backs without any support or wedges in place, while the wedges intended for their use were observed on their dressers instead of being utilized. For one resident, documentation showed a history of non-compliance with offloading and repositioning, but education was provided and the resident verbalized understanding. The resident's care plan included frequent repositioning and the use of pressure-relieving devices, yet on observation, the resident was not positioned as required. The wound report indicated deterioration of a sacral ulcer, and the care plan emphasized the need for interventions to maintain skin integrity. Staff interviews confirmed that repositioning and the use of wedges were expected practices, but these were not consistently implemented. The second resident, who had multiple stage 2 and stage 4 pressure ulcers and severe cognitive impairment, was also observed lying on her back without support. Her care plan and medical orders required repositioning every two hours and the use of pressure-reducing devices. Staff interviews revealed that repositioning was sometimes delayed or omitted, particularly after bathing or in anticipation of wound care. The facility's policy required repositioning and the use of positioning devices to prevent pressure injuries, but these measures were not consistently followed, as evidenced by the observations and staff statements.