Failure to Provide Adequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries and to promote healing for two residents, both with significant risk factors and existing pressure injuries. For one resident with multiple sclerosis and spastic paraplegia, there were multiple instances of inaccurate or incomplete wound assessments, including incorrect staging of pressure injuries and lack of detailed wound bed descriptions. After hospitalizations, assessments were delayed, and some areas previously identified as pressure injuries were not reassessed by a registered nurse or wound specialist until several days after readmission. Additionally, prescribed treatments were not consistently administered, as observed when a nurse failed to apply the ordered treatment to a pressure injury on the resident's right lateral foot. During morning care, staff did not apply skin protectant as ordered, and the nurse manager confirmed that this should have been done. For the second resident, who was at risk for pressure injury development due to immobility, incontinence, and recent fracture, staff failed to implement required preventive measures. The resident's care plan and CNA worksheet specified the use of heel suspension boots and offloading of heels while in bed. However, repeated observations by the surveyor over several days found the resident in bed without the boots on and heels not offloaded. Despite this, nursing staff documented in the treatment administration record that the boots were in place and heels were offloaded, which was inconsistent with direct observations and staff interviews. The LPN confirmed that if the resident refused the boots, this should have been documented, but there was no such documentation. The facility's policy on pressure injury assessment and treatment did not address the required assessment process upon admission or readmission, nor did it specify the necessary components of a pressure injury assessment. Interviews with nursing staff revealed inconsistent understanding and application of wound assessment standards, including staging and wound bed description. These failures resulted in inadequate monitoring, documentation, and implementation of pressure injury prevention and treatment protocols for residents at risk or with existing wounds.