Failure to Prevent and Manage Pressure Ulcer in High-Risk Resident
Penalty
Summary
A deficiency occurred when a male resident with multiple comorbidities, including Type 2 Diabetes Mellitus, heart disease, hypertension, hyperlipidemia, and osteoporosis, developed an unstageable pressure ulcer during his stay at the facility. Upon admission, a head-to-toe assessment was completed, and the only noted skin issue was a surgical dressing on the right hip and bruising on both hands. The resident was care planned for skin care issues, including being kept dry, use of barrier cream, and regular repositioning, as he was unable to reposition himself and required two-person assistance. Despite these interventions being documented, a pressure ulcer was identified on the coccyx area after a CNA noticed an open area following a shower, and subsequent assessment confirmed the presence of an unstageable wound with eschar and slough. Interviews with nursing staff and the DON revealed that the resident was at risk for pressure ulcers due to his inability to reposition himself and incontinence. Staff acknowledged that lack of repositioning and not changing a resident in a timely manner could contribute to wound development. The wound care doctor and nursing staff stated that the resident was provided with a pressure-reducing mattress, barrier cream, and was to be repositioned every two hours or more as needed. However, the development of the pressure ulcer indicated a failure to ensure that these interventions were effectively implemented or monitored, as the wound was not present upon admission and developed during the resident's stay. The facility's policy required protocols for prevention, identification, assessment, and management of skin conditions and pressure ulcers, but the occurrence of the pressure ulcer in this resident demonstrated a lapse in adherence to these standards. The deficiency was identified as Immediate Jeopardy due to the failure to provide care consistent with professional standards of practice to prevent pressure ulcers and ensure necessary treatment and services for residents at risk.