Failure to Prevent and Manage Pressure Ulcers Due to Inadequate Assessment and Intervention
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and heal pressure injuries for two residents. For one resident, who was at risk for skin breakdown due to multiple comorbidities including a recent hip fracture, diabetes, chronic kidney disease, and impaired mobility, the facility did not accurately identify, document, evaluate, or monitor a developing pressure ulcer. The skin breakdown was initially documented as moisture-associated skin damage (MASD) and later as an abrasion, but the area was not recognized or treated as a pressure injury. Weekly skin assessments were inconsistent and incomplete, failing to identify the wound's progression, and the care plan did not include timely interventions such as an air mattress until after the wound had developed. Upon discharge, the resident was found by the receiving facility to have an open wound with slough, which was later identified as a Stage 4 pressure ulcer with exposed bone. For another resident with quadriplegia and a known Stage 4 pressure ulcer, the facility did not ensure consistent implementation and documentation of wound prevention and care interventions. Observations revealed that the resident's air mattress and wound vac settings were not consistently monitored or documented, and there were lapses in the application of barrier cream and repositioning. The care plan and treatment administration records showed missing documentation for multiple wound care and prevention interventions, and the physician was not notified of changes in the resident's skin condition, including the development of MASD and maceration around the wound. Staff interviews confirmed that wound care was not always measured or documented as required, and that the function and settings of pressure-relieving devices were not routinely checked or recorded. Both cases demonstrated a lack of thorough and accurate assessment, documentation, and timely intervention for pressure injuries. The facility did not follow its own policies for skin evaluation, risk assessment, and physician notification when new or worsening skin conditions were identified. These failures resulted in unaddressed and undocumented pressure injuries, incomplete care plans, and inadequate monitoring of wound care interventions and pressure-relieving equipment.