Failure to Prevent and Treat Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to ensure that appropriate pressure ulcer prevention interventions were initiated, implemented, monitored, and documented for a resident identified as being at risk for pressure injuries, who developed a pressure ulcer during their stay. The facility's policy required comprehensive skin assessments upon admission and weekly for four weeks, as well as head-to-toe skin observations during showers and regular repositioning for bed-bound residents. However, documentation revealed that only limited skin assessments were completed during the resident's five-day respite stay, with no evidence of consistent monitoring or timely intervention when skin changes were noted. The resident in question was admitted for respite care with multiple complex medical conditions, including morbid obesity, acute respiratory failure, chronic heart failure, peripheral vascular disease, and severe cognitive impairment. The care plan indicated the resident was bed-bound, fully dependent for all activities of daily living, and required total assistance with bed mobility and self-care. Despite these risk factors, the electronic medical record showed that only two skin assessments were documented, and there was no evidence of regular repositioning or implementation of other pressure ulcer prevention measures as outlined in the facility's policy. When a pressure ulcer was identified on the resident's left heel, a physician's order for wound care was written, but there was no documentation that the treatment was provided or that the order was carried out. Interviews with staff confirmed that wounds should be reported and treated promptly, but no treatment notes or interventions were found in the record. Additionally, there was no documentation of care plan updates or evidence that staff addressed difficulties with repositioning the resident, despite reports of such challenges. This lack of assessment, intervention, and documentation contributed to the development and lack of treatment for the pressure ulcer.