Failure to Implement Pressure Injury Prevention Measures for High-Risk Resident
Penalty
Summary
A resident with a history of Alzheimer's disease, dementia, prior CVA with right-sided contractures, right lower extremity osteomyelitis, and multiple comorbidities was admitted for respite care. Upon admission, the resident was assessed as being at high risk for pressure wounds due to severe frailty, immobility, and peripheral vascular disease. Physician recommendations included frequent turning and repositioning, use of positioning supports such as wedges and heel protectors, pressure redistributing mattress, and daily wound care. However, these recommendations were not transcribed into the resident's care plan or implemented in daily care routines. During the resident's stay, the baseline plan of care only included general interventions such as daily skin inspection, moisturizing, and encouraging nutrition, but omitted specific physician-ordered interventions for pressure injury prevention. Staff interviews and record reviews revealed that the resident was not provided with an air mattress, heel boots, or adequate offloading supports, despite these items being available in facility supply. Documentation in the Treatment Administration Record showed completion of some skin care interventions, but there was no evidence of regular turning, repositioning, or use of pressure-relieving devices as ordered. The wound care nurse and DON were unaware of the resident's deteriorating skin condition until notified by the resident's representative. The deficiency was identified when the resident's representative discovered multiple new pressure wounds on the resident's right foot, heel, and knee, which were not present prior to admission. The wounds were severe enough to require emergency transfer to the hospital, where the resident was diagnosed with severe sepsis and ultimately underwent a right foot amputation. Facility staff confirmed that the required interventions for pressure injury prevention were not consistently implemented, and the care plan did not reflect the physician's recommendations for high-risk skin care management.