Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure injuries for three residents who were either at risk for or had existing pressure injuries. One resident was admitted without any pressure injuries but was assessed as at risk. Ten days after admission, this resident developed a blister on the left buttock that was not assessed by a Registered Nurse, and the care plan was not revised when the area declined. Aggressive interventions, such as repositioning, were not implemented even after the resident refused an air mattress. The wound continued to deteriorate, eventually becoming infected and requiring antibiotics and surgical debridement, after which it was staged as a stage 4 pressure injury. The facility's documentation and care planning were inconsistent and incomplete. There was a lack of comprehensive assessment and timely updates to care plans following changes in the residents' conditions. For the resident who developed the stage 4 pressure injury, there was no evidence of a Registered Nurse or physician assessment upon discovery of the wound, and the care plan did not address repositioning or alternative interventions after the resident refused the air mattress. Additionally, there was no documentation of the resident refusing to be repositioned, and no interventions were added to address this aspect of care. The facility also failed to assess or offer alternative support surfaces beyond the standard mattress and air mattress. Other residents at risk for or with pressure injuries were also not consistently repositioned according to their care plans, as observed by surveyors and reported by family members. One resident was not repositioned during multiple observations, and another was readmitted without a comprehensive assessment of their pressure injury and was not offloaded or repositioned as required. The facility's own wound management policy, which requires comprehensive assessment and interdisciplinary care planning, was not followed, contributing to the deficient practice.