Failure to Assess and Prevent Pressure Ulcers Post-Surgery
Penalty
Summary
The facility failed to complete necessary assessments and implement appropriate interventions to prevent pressure ulcers for a resident who was readmitted after a total right knee arthroplasty. Upon readmission, the resident was identified as being at risk for pressure injuries and was dependent on staff for bed mobility. Despite this, there was no documentation that licensed staff removed the resident's compression stockings to assess the skin on the right leg and foot during the initial and subsequent skin assessments. Staff interviews confirmed that the compression stockings were not removed for visual inspection, and the care plan was not updated to reflect the resident's increased risk following surgery. Over a period of several days, there was no evidence that the resident's right foot was assessed, even though the resident was experiencing increased pain. Staff did not document any refusals of care or notify the medical provider about the inability to assess the resident's skin. When the compression stocking was finally removed, multiple pressure injuries were discovered, including unstageable pressure injuries with black eschar and a deep tissue pressure injury on the right foot. The resident was subsequently transferred to a hospital for further care. Interviews with nursing staff and management revealed that there was a lack of adherence to facility policy regarding daily and weekly skin assessments, especially for residents with devices such as compression stockings. The care plan was not revised after the resident's surgery, and there was no communication with the provider regarding unclear orders for the compression stockings or the resident's pain and refusal to allow assessment. These failures resulted in the development of significant pressure injuries.