Failure to Prevent and Treat Pressure Injuries According to Standards of Practice
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for the prevention and treatment of pressure injuries in a resident with a history of pressure ulcers and significant risk factors. The resident was inaccurately assessed as not at risk for pressure injury development upon admission, despite a documented history of pressure injuries and decreased mobility. This led to an insufficient care plan that did not adequately address the resident's risk factors or include robust interventions to prevent pressure injuries. The care plan was not updated in a timely manner as the resident's condition changed, and interventions to prevent worsening or new injuries were not implemented promptly. Staff inconsistently staged and documented the resident's wounds, failing to provide detailed descriptions of wound characteristics in weekly assessments. There were discrepancies in wound staging, with some wounds being down-staged contrary to standards of practice, and incomplete documentation regarding the extent of granulation and epithelial tissue. Additionally, wound assessments and documentation were sometimes kept outside the resident's official medical record, leading to gaps in continuity of care. The resident's wounds showed signs of deterioration and infection, but the medical doctor was not notified in a timely manner about these changes. The facility also failed to follow physician orders for wound care and did not provide the resident with information about the risks and benefits when he refused to wear offloading boots, which were prescribed for treatment. Staff did not consistently follow standards of practice during wound care procedures, and treatment orders were not always implemented as prescribed. As a result of these failures, the resident developed multiple stage 3 or unstageable pressure injuries, including an infected wound, which constituted a finding of Immediate Jeopardy.