Failure to Identify and Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to identify and report an alteration in skin integrity for a resident at risk for pressure ulcers, resulting in the development of a Stage 2 pressure ulcer on the resident's tailbone. The resident's care plan included interventions for monitoring, turning, and repositioning at least every two hours, and required immediate nurse notification of any new skin breakdown. However, CNA documentation over a one-month period did not note any skin issues, and the Assistant Director of Nursing was unaware of the sore until it was discovered following a fall. The LPN stated that CNAs were responsible for repositioning, but expressed uncertainty about how to reposition a resident in a geriatric chair, which the resident used most of the day. Subsequent assessments by hospice and wound care staff identified a pressure ulcer on the resident's tailbone, with the wound care provider determining it was a Stage 2 ulcer that had developed three to four weeks prior, not as a result of the fall. The facility's own policy required assessment, monitoring, and documentation of skin breakdown, but these steps were not effectively carried out, leading to a failure to prevent the pressure ulcer.