Failure to Provide Timely Pressure Ulcer Prevention and Care
Penalty
Summary
A dependent resident with dementia and a recent right hip fracture, who required significant assistance with activities of daily living and was at risk for skin breakdown, was not provided timely and adequate care to prevent the development and worsening of a pressure ulcer. The resident was left in a recliner chair overnight, in the same clothes and position, without being repositioned or provided with incontinence care, despite being frequently incontinent of bladder and always incontinent of bowel. Staff documented that care was provided, but interviews revealed that no care or pressure prevention interventions were actually performed during the night shift, and the resident's refusal of care was not documented in the nurse notes for the relevant dates. The resident's family discovered the resident in soiled clothing and linens, with a sore on the left heel and dried blood on the sheets that had not been changed for three days. Upon assessment, a deep tissue injury (DTI) was identified on the resident's left heel, which progressed to an unstageable pressure ulcer with eschar and drainage. Observations showed that the heel protector was not consistently in place, and the ordered air mattress was not present on the resident's bed during multiple checks. The care plan and Braden Scale assessments indicated the resident was at risk for pressure ulcers, but appropriate interventions to prevent further skin breakdown were not implemented in a timely manner after the injury was identified. Facility policies required assessment and preventative interventions for residents at risk of pressure injuries, including offloading heels, repositioning, and use of pressure redistribution devices. However, these measures were not consistently followed for this resident, as evidenced by the lack of timely intervention, inconsistent use of protective devices, and failure to document or address care refusals. The delay in implementing physician-ordered treatments and pressure-relieving equipment contributed to the worsening of the resident's pressure ulcer.