Failure to Prevent and Treat Pressure Injuries per Professional Standards
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards of practice to prevent and treat pressure injuries (PIs) in two of three sampled residents. For one resident with a history of a stage IV pressure injury, the facility did not consistently implement prescribed interventions, such as the use of a pressure redistribution cushion in the wheelchair, which was observed to be missing or improperly placed. Wound assessments were not completed weekly as required, and there were delays in initiating and documenting wound treatments. Treatment Administration Records (TARs) contained multiple blanks, indicating that ordered treatments were not completed or not documented as done. Interviews with staff confirmed that if the TAR was blank, the treatment was not performed. Another resident, who was at high risk for pressure injuries due to paraplegia, had a pressure injury that was not accurately staged according to professional guidelines. The wound was documented as a stage II pressure injury despite the presence of slough, which is inconsistent with the definition of stage II. This resident also had multiple instances where wound care treatments were not completed as ordered, as evidenced by numerous blanks in the TAR across various shifts and dates. Staff interviews corroborated that these blanks meant treatments were not provided. The facility's own policy required comprehensive assessment and documentation of skin integrity upon admission and for new or worsening wounds, as well as routine wound rounds and adherence to the most recent NPIAP guidelines. Despite these policies, both residents experienced lapses in care, including missed or delayed wound assessments, incomplete or undocumented treatments, and failure to ensure the use of prescribed pressure-relieving devices. These deficiencies were confirmed through observation, record review, and staff interviews.