Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide proper care to prevent the development of a right heel pressure ulcer for a resident who was clinically compromised and totally dependent on staff for mobility. Upon admission, the resident had multiple diagnoses, including muscle wasting, spastic quadriplegic cerebral palsy, and impaired lower extremities, making them at high risk for pressure injuries. The admission assessment did not identify any existing pressure sores or wounds on the right heel, and there was no care plan initiated to prevent pressure injuries, such as offloading the feet or conducting daily skin assessments. The deficiency was identified when the wound treatment nurse discovered a darkened area with 100% necrosis on the resident's right heel during wound care, which was not present at admission. Interviews with staff confirmed that a care plan for pressure injury prevention, including offloading and daily skin checks, was not in place at the time of admission. The facility's policy required daily skin inspections and individualized interventions based on risk factors, but these were not implemented for this resident prior to the development of the pressure ulcer.