Failure to Perform Ongoing and Accurate Pressure Ulcer Assessment and Prevention
Penalty
Summary
The facility failed to perform ongoing and accurate assessment of pressure ulcers for two residents who were at risk for pressure ulcer development. For one resident with diagnoses including dehydration, Parkinson's disease, anxiety, and weakness, the Braden Scale indicated a moderate risk for pressure ulcers. Upon admission, this resident had multiple wounds, including a dehisced scar, an unstageable ulcer on the left buttock, and a scratch on the arm. Wound assessments documented changes in wound status, including the development of new pressure ulcers and worsening of existing wounds, but lacked consistent and complete documentation of wound characteristics, frequency of assessments, and specific interventions. The care plan and Kardex lacked clear directions for staff regarding mobility, transfers, repositioning, and toileting frequency, despite the resident's incontinence and need for assistance. Progress notes and interviews revealed that the resident was often found incontinent and not cleaned up, with reports of frequent exposure to feces and the development of additional sores during the facility stay. Another resident with diagnoses of dementia, heart disease, pain, and a history of falls was also identified as high risk for pressure ulcers based on the Braden Scale. The care plan directed staff to check for incontinence every two to three hours and to assist with frequent repositioning, but wound assessments were not consistently completed. There was a lack of documented wound assessments for a period of over three weeks, despite the presence of a pressure ulcer on the sacrum and an open area on the coccyx. Staff interviews confirmed that wound charting was inconsistent, and the facility did not have a process for regular wound rounds. The DON acknowledged that skin checks were supposed to be completed weekly but were not being done for this resident. Facility policy required that pressure ulcers be evaluated at least weekly, with RNs responsible for recording wound type and degree of tissue damage, and licensed nurses documenting location, measurements, and characteristics. However, the facility failed to adhere to these requirements, resulting in incomplete and infrequent wound assessments, lack of clear staff direction, and insufficient implementation of interventions to reduce the risk of new or worsening pressure ulcers for residents at risk.