Delayed Pressure Ulcer Prevention and Inadequate Monitoring
Penalty
Summary
The facility failed to adhere to professional standards for the care and management of pressure ulcers for one resident. Upon admission, the resident had a history of a healed sacral wound with no open areas or drainage, and the initial skin assessment did not identify any current pressure ulcers. Despite being dependent on staff for most activities of daily living and having multiple comorbidities, preventive interventions such as an air mattress and wedge cushions were not implemented until several weeks after admission. The care plan for skin integrity was initiated, but specific interventions for pressure ulcer prevention were delayed, with the air mattress ordered approximately four weeks after admission and the wedge cushion about seven weeks after admission. Interviews with the wound care LPN revealed that although the resident was identified as being at risk for pressure ulcers, preventive measures were not immediately provided because there was no open wound at admission. The LPN admitted to not performing weekly skin assessments as required and only reassessed the resident after being notified of skin breakdown. Documentation was inconsistent, with late entries in the nursing progress notes, and the LPN acknowledged not knowing why weekly skin notes were not completed. The resident's condition deteriorated, and within a month, a stage 4 pressure ulcer developed, which the LPN stated was unusual for a resident with no initial skin openings. Additional staff interviews indicated that while some preventive measures such as barrier creams and frequent repositioning were reportedly followed, there was a lack of consistent monitoring and oversight of these interventions. The staff also noted the resident's frequent refusal of care, but could not specify when this behavior began. The delay in implementing appropriate preventive measures and inconsistent documentation and monitoring contributed to the development and worsening of the resident's pressure ulcer.