Failure to Prevent Pressure Ulcers Under Cervical Collar
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice to prevent pressure ulcers for a resident with a cervical collar (C-collar). The resident, who had diagnoses including dementia, vertebral artery dissection, and cervical vertebra fractures, was admitted and readmitted to the facility without any initial evidence of pressure ulcers. Physician orders specified that the C-collar should be worn at all times except during showers, with a soft collar to be used for bathing. However, there were no orders or documented interventions for regular removal of the collar to perform skin checks, and the care plan did not address brace removal for skin assessment. Observations and interviews revealed that staff did not consistently remove the C-collar to assess the skin underneath, as required by facility policy and professional standards. The collar was found to be taped in place, with excessive tape wrapped around it, and was soiled with fecal matter and food. Nursing staff, including the treatment nurse and LVNs, reported not removing the collar for thorough skin assessments, and some staff were unaware of the presence or purpose of the tape. The resident was only documented as receiving baths on two occasions, and during these times, the collar was not always removed. When the resident was sent to the emergency room, hospital staff discovered unstageable pressure ulcers, wounds behind the ear and on the chin, and noted a strong odor and signs of infection under the collar. Interviews with facility staff and the resident's physician confirmed that proper procedures for skin assessment under immobilization devices were not followed. The physician stated that the collar should be fitted correctly and removed for skin checks as appropriate, and the facility's own policies required periodic removal of immobilization devices for skin assessment and cleanliness. Despite these requirements, staff failed to perform adequate skin checks, did not document concerns about the tape or soiling, and did not follow up with appropriate interventions to prevent pressure ulcers. These failures resulted in the development of unstageable pressure ulcers and an Immediate Jeopardy situation.