Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including Multiple Sclerosis, cerebral infarction, major depressive disorder, muscle weakness, and heart failure, was not provided with appropriate pressure ulcer prevention and care as outlined in facility policy and physician orders. The resident, identified as being at risk for pressure injuries, had a stage 2 pressure injury to the coccyx. The care plan and physician orders specified the use of a pulsating mattress, a pressure offloading cushion when up in a chair, and repositioning every 30 minutes. However, during the survey, the resident was observed sitting in a recliner without a cushion, and the specialty mattress was set to static rather than pulsate. Staff did not encourage or assist the resident to reposition during the nearly hour-long observation period. Further review revealed that the Resident Profile sheet used by CNAs to guide care did not include any pressure injury prevention interventions, despite these being present in the care plan and physician orders. Interviews with CNAs and the DON confirmed that the necessary interventions were not being followed, and the DON acknowledged that the resident's pressure injury prevention devices were not in place as required. The lack of implementation and communication of pressure injury prevention measures directly contributed to the deficiency.