Failure to Implement and Document Pressure Ulcer Prevention and Care
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate pressure ulcer prevention and care for two residents identified as at risk for pressure injuries. One resident was admitted without pressure injuries but was at risk due to immobility, incontinence, and other medical conditions. The Braden Scale assessment for this resident was inaccurately completed, and required weekly assessments were not performed as per facility policy. No preventive care plan interventions, such as offloading, scheduled turning and repositioning, or incontinence management, were implemented initially. The resident subsequently developed a facility-acquired unstageable pressure injury, which became infected and required advanced wound care, including debridement, antibiotics, and a wound vacuum. The care plan was not updated with new interventions after the injury was identified, and recommended treatments were not consistently completed as ordered. There was also a documented incident where the resident was not checked or changed for an entire night shift, and this lapse was not immediately addressed in the care plan. Another resident, also identified as at high risk for pressure injuries due to immobility and cognitive impairment, did not have care plan interventions for offloading heels implemented as observed by the surveyor. Despite care plan instructions and documentation in the Kardex for heel offloading, repeated observations showed the resident's heels were not offloaded and were pressed against the footboard. Staff interviews revealed that refusals of care by the resident were not consistently documented, and there was no care plan in place for managing refusals until after the survey began. The lack of documentation and implementation of preventive interventions persisted over multiple observations. The facility's policy required risk assessments, identification and implementation of interventions, and regular care plan updates based on changes in condition or the development of pressure injuries. However, these procedures were not followed for both residents. The surveyor found that the facility did not ensure care and services were provided according to professional standards to prevent pressure injuries, nor did it ensure necessary treatment and services were provided to promote healing and prevent new ulcers from developing.
Removal Plan
- A facility-wide skin sweep audit was completed for all in house residents to identify anyone with existing or potential pressure injuries.
- Residents Braden assessments were completed for all in house residents.
- Pressure ulcer prevention interventions were verified for all at-risk residents, including care plan updates if needed. If a new intervention was needed, it was implemented.
- Reviewed the Illuminus policy to ensure compliance with CMS and Wisconsin DBS guidance.
- Re-educated all nursing staff on proper process for staging wounds and the required weekly documentation of each wound and an entered intervention.
- Re-educated all nursing staff on pressure injury prevention and skin integrity, including accurate and timely documentation of skin assessments and treatments.
- Re-educated all nursing staff on importance of repositioning, offloading, and movement.
- Facility will audit up to 4 residents with wounds a week, focusing on proper staging and documentation.
- DON and/or designee will be responsible for these audits. All results will be reported to QAPI committee for future action or adjustment.
- Practice is to follow National Pressure Ulcer Advisory Panel Standards along with the Critical Element Pathway for pressure injuries.
- WCC nurse is credentialed by the wound care educational institute.