Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement and maintain appropriate interventions to prevent the development of pressure ulcers for two residents identified as being at risk. One resident, who was severely cognitively impaired and had multiple comorbidities including dementia, diabetes, malnutrition, and mobility limitations, was documented as requiring assistance with most activities of daily living and was noted to be at risk for pressure ulcers. Despite care plans indicating the use of pressure-reducing devices and weekly skin checks, the resident developed multiple new wounds, including a stage 3 pressure ulcer. Observations and interviews revealed that interventions such as offloading devices were not consistently in use, and staff did not always remove socks during skin assessments, potentially missing early signs of skin breakdown. Another resident, also at risk for pressure ulcers and requiring moderate assistance with daily activities, was found to have developed a sacral pressure ulcer that was acquired in-house. Nursing notes indicated the presence of an unassessed wound with odor and abnormal appearance, and subsequent documentation confirmed the wound as a pressure ulcer. The care plan for this resident included weekly skin checks, but the wound was not identified in a timely manner, and the skin assessment did not reflect the presence of new wounds. Policy review showed that the facility's guidelines required evidence-based interventions and thorough skin inspections for residents at risk of pressure injuries. However, staff interviews and documentation revealed lapses in the implementation of these preventive measures, including incomplete skin assessments and inconsistent use of pressure-relieving devices. These failures contributed to the development of avoidable pressure ulcers in both residents.