Failure to Implement and Document Pressure Ulcer Prevention and Timely Treatment
Penalty
Summary
A deficiency was identified when a resident at risk for pressure ulcers did not have care planned interventions in place to prevent skin breakdown, which resulted in the development of a pressure ulcer. The resident had significant risk factors, including a history of stroke with right-side paralysis, severe malnutrition, incontinence, and dependence on staff for mobility and personal care. Despite these risks, the resident's care plan and Kardex did not include specific interventions or measurable goals related to pressure ulcer prevention, and there was no documentation of preventative measures being implemented. Upon identification of a new deep tissue injury to the resident's sacrum, there was a delay of three days before wound treatment orders were documented and implemented. Progress notes indicated that the wound was first noted as a reddened area, and a note was placed in the medical provider book, but no immediate interventions or treatment orders were initiated. The wound care provider assessed the injury the following day and recommended specific treatments and preventative measures, but these were not ordered until three days after the initial identification of the wound. Interviews with facility staff revealed inconsistent understanding and implementation of pressure ulcer prevention protocols. Certified nursing assistants and nurses reported relying on the Kardex for instructions, but the Kardex did not address the resident's pressure ulcer risk. Staff described general prevention strategies such as repositioning and incontinence care, but these were not consistently documented or included in the resident's care plan. The Director of Nursing confirmed that care plans should include wounds and appropriate interventions, but in this case, the necessary preventative and treatment measures were not in place or documented in a timely manner.