Failure to Provide Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide necessary treatment and preventive care for a resident at risk for pressure ulcers, resulting in the development of multiple pressure injuries. Upon admission, the resident had several risk factors, including diabetes, stroke, hemiplegia, malnutrition, and severe cognitive impairment, and was dependent on staff for mobility and self-care. Initial assessments documented redness to the heels, groin, buttocks, and eschar to the left big toe, but the wound care team was not notified, and preventive interventions such as pressure-relieving devices were not implemented in a timely manner. The care plan included interventions like barrier cream, frequent repositioning, and skin monitoring, but there was a lack of consistent follow-through and communication among staff regarding these interventions. Over the course of the resident's stay, staff failed to monitor and respond to early signs of pressure injury, particularly on the heels and sacrum. Weekly skin assessments inconsistently documented skin issues, and the wound care nurse did not recognize or escalate concerns about developing wounds. The wound care nurse also demonstrated a lack of knowledge regarding wound staging and did not consult the wound medical doctor when significant skin changes were identified. Observations and interviews revealed that pressure offloading devices, such as wedges and heel protectors, were not properly placed or used, and staff were unclear about their correct application and purpose. Additionally, there was inadequate documentation and monitoring of repositioning and offloading interventions. As a result of these failures, the resident developed a Stage 3 pressure ulcer on the sacrum and multiple deep tissue injuries to the heels and toes, which were not present on admission. The facility's own policies and professional standards of practice for pressure ulcer prevention, including timely assessment, use of pressure-relieving devices, and appropriate staff communication, were not followed. These deficiencies were identified through observations, interviews, and record reviews, and placed residents at risk for new or worsening pressure ulcers.