Failure to Provide Consistent Pressure Ulcer Prevention and Care
Penalty
Summary
Facility staff failed to provide adequate pressure ulcer care and prevention for one resident, resulting in the development of new pressure injuries and deterioration of existing wounds. The resident, who had multiple complex medical diagnoses including hypertension, diabetes, morbid obesity, hemiplegia, and pre-existing wounds, was admitted with significant risk factors for pressure injury development. Despite being assessed as moderate risk on the Braden Scale and requiring extensive assistance with mobility and ADLs, the resident did not consistently receive the ordered interventions and assessments necessary for pressure ulcer prevention and management. Clinical record review revealed missed or incomplete wound assessments on specific dates, as well as gaps in the administration of prescribed treatments and nutritional supplements intended to promote wound healing. Documentation showed that the air mattress, which was ordered to reduce pressure, lacked evidence of being in place or regularly checked for functionality. Additionally, the care plan interventions for turning and repositioning were not consistently implemented or documented, with multiple instances of missing or incomplete CNA documentation regarding repositioning and ADL care. Further review of medication and treatment administration records identified multiple days where wound care treatments and supplements such as Prostat, MVI, and Zinc were not administered as ordered, either due to being on order, not available, or left blank. The facility's own policies required weekly skin risk assessments and documentation of interventions, but these were not consistently followed. The cumulative effect of these failures led to the resident developing new Stage 2 and Stage 3 pressure injuries and a lack of timely response to changes in wound status.