Failure to Prevent New Pressure Ulcer in Resident
Penalty
Summary
A deficiency occurred when a resident, admitted with multiple diagnoses including a pathological fracture, congestive heart failure, atrial fibrillation, and osteoporosis, developed a new pressure ulcer on her left heel after admission. Upon admission, the resident was noted to have a surgical wound to her left hip but no other skin issues, and was assessed as cognitively intact but requiring maximum assistance with transfers and bed mobility. The initial skin check performed by an LPN and the nurse manager did not reveal any open areas or redness on the resident's heels. However, approximately one week later, staff alerted the LPN to a pressure ulcer on the resident's left heel, which was found to be unstageable with black tissue present. The facility's care plan for the resident included interventions such as applying ace wraps to both lower extremities, keeping the skin clean and lubricated, monitoring bony prominences for redness, using pillows to avoid direct contact with bony prominences, and utilizing pressure-relieving devices. Despite these interventions, the pressure ulcer developed. The LPN and DON indicated that skin checks were performed weekly, and suggested that the ulcer may have developed between checks. It was also noted that daily full inspections of the feet may not have been performed, especially since the resident's legs were wrapped with ace wraps per physician orders. The facility's policy required systematic assessment, identification of risk factors, and early interventions, but the new pressure ulcer was not identified until it had progressed.