Failure to Timely Assess, Treat, and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely assessment and treatment of pressure ulcers, as well as the implementation of prevention measures for residents at risk. For one resident with a history of traumatic brain injury, contractures, and functional quadriplegia, the care plan included floating heels to prevent pressure injuries. However, observations on two separate occasions revealed that the resident's heels were not floated while in bed, and staff confirmed this intervention was not consistently implemented. Another resident was admitted with a blackened area on the left toe, but the initial assessment and treatment orders for the pressure ulcer were not obtained until the day after admission. The DON confirmed that LPNs are responsible for obtaining treatment orders, but staging of pressure ulcers should be performed by an RN, which was not done promptly. Additionally, a third resident developed a deep tissue injury to the right heel while in the facility, and skin integrity interventions such as floating heels and a turn/reposition schedule were not added to the care plan until after the injury was identified. The DON confirmed that these interventions were not in place prior to the discovery of the pressure injury, and that the injury was acquired in-house. These findings demonstrate a lack of timely assessment, intervention, and prevention practices for pressure ulcers among residents reviewed.