Failure to Implement Pressure Ulcer Prevention for High-Risk Resident
Penalty
Summary
A resident was admitted to the facility following surgery to place a rod in her left leg and was dependent on staff for repositioning and pain management. Upon admission, the resident had a full-length cast, was non-weight-bearing, and required moderate to maximum assistance for movement. The initial skin assessment documented a large, red, flaky, and macerated area on her buttocks, but no open wounds. The resident's Braden Scale score indicated she was at risk for developing pressure ulcers, and she was placed on an air mattress. However, the care plan was not completed to address her specific needs, including her cast, wound vac, urinary catheter, transfer status, risk for pressure ulcers, or interventions for prevention. Documentation and interviews revealed that the resident remained in bed for several days, experienced significant pain, and was only repositioned as tolerated. Staff noted that she sometimes refused repositioning due to discomfort, and there was inconsistent documentation of repositioning tasks. Nursing staff and CNAs were unclear about the frequency and extent of repositioning provided, and there was a lack of clear communication and documentation regarding her care. The wound nurse and DON were not present during the resident's stay, and no baseline care plan or wound data collection form was completed. The expectation was that interventions such as frequent repositioning and skin care would be implemented, but these were not documented or consistently carried out. The resident developed a Stage II pressure ulcer to her coccyx and associated moisture-related skin damage to her perineum, which was not present upon admission. The physician confirmed that these skin injuries were preventable and not present when the resident was discharged from the hospital prior to admission to the facility. The facility's own wound care protocols required comprehensive management and documentation for residents at risk, but these were not followed. The lack of a completed care plan, failure to implement and document preventive interventions, and insufficient staff communication contributed to the resident developing a pressure ulcer during her stay.