Failure to Implement Pressure Ulcer Prevention Interventions for High-Risk Resident
Penalty
Summary
A resident with multiple comorbidities, including chronic obstructive pulmonary disease, malnutrition, osteoporosis, cancer, and cognitive impairment, was identified as being at risk for pressure ulcer development. The resident was dependent on staff for all mobility and transfers and was incontinent of bowel and bladder. Despite these risk factors, the care plan did not include specific interventions for the use of pressure-relieving devices for the resident's chair or bed, even though the Minimum Data Set indicated such devices should be used. Braden assessments initially rated the resident as low risk, but this was later determined to be inaccurate given the resident's condition. During multiple observations, the resident was seen in a reclining wheelchair without a pressure-relieving cushion and was not repositioned for at least three consecutive hours, contrary to facility policy requiring repositioning every two hours. Staff interviews confirmed that pressure-relieving cushions were expected for all residents at risk, but the resident had not received one. Additionally, the resident was found to have red, blanchable areas on the coccyx and ankles, which progressed to a non-blanchable area with skin peeling over the coccyx, indicating the development of a pressure injury. Documentation review revealed that no new physician orders or treatments were in place for the coccyx area at the time of the deficiency, and the resident was still on a standard mattress rather than a pressure-reducing mattress. Staff acknowledged that the Braden assessment had been completed incorrectly and that the resident should have been classified as higher risk. The facility's policy required special mattresses and chair cushions for high-risk residents, but these interventions were not implemented prior to the development of the pressure injury.