Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide appropriate care and services to prevent pressure ulcers for one resident. Upon readmission, the resident was noted to have redness on the buttocks, and assessments documented that the resident was dependent on staff for toileting and required moderate assistance for turning in bed. Despite these risk factors, there were no physician orders or care plan interventions in place to prevent skin breakdown prior to the development of pressure ulcers. The care plan did not reflect that the resident was at risk for pressure ulcers until after the wounds had developed. Subsequent assessments revealed the resident developed an open wound to the sacrum and left buttocks, which progressed to a Stage 4 pressure ulcer on the sacrum and a Stage 3 pressure ulcer on the left buttocks. Documentation showed that the resident's family was not informed about the initial redness upon readmission. Interviews with facility staff confirmed that there were no preventive interventions ordered or implemented before the pressure ulcers occurred.