Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to identify, assess, and provide appropriate treatment for pressure ulcers for a resident who was severely cognitively impaired and dependent on staff for all activities of daily living. The resident was assessed as high risk for pressure ulcers and had care plan interventions in place, including floating heels and using pillows or cushions to prevent skin-to-skin contact and pressure on the legs and feet. Despite these interventions and physician orders for daily skin checks and monitoring of red areas on the legs, staff did not implement the prescribed preventative measures. Observations over several days showed the resident lying in bed with bare legs directly on the fitted sheet, without heel protectors, pillows, or cushions in place. Documentation revealed that the resident developed a Stage II pressure ulcer on the right inner leg and a Stage I pressure ulcer on the left posterior leg, with no prior physician orders or assessments for these wounds before their identification. Staff interviews confirmed a lack of awareness and action regarding the need for skin protection and preventative measures, and the facility administrator acknowledged that the pressure ulcers were known but not addressed or documented as required by facility policy. The facility's policy mandated daily skin inspections and positioning according to the care plan, which was not followed in this case.