Failure to Implement Resident-Specific Interventions for Pressure Ulcers
Penalty
Summary
The facility failed to implement appropriate and resident-specific interventions for a resident who developed two unstageable pressure ulcers during their stay. The resident, who had no cognitive impairment as indicated by a BIMS score of 15, was not admitted with these wounds, which were documented as acquired in the facility. The care plan, revised on 12/12/25, noted multiple pressure areas but lacked detailed interventions tailored to the resident's needs, such as specific treatments, medications, supplies, pain management strategies for wound care, and input from the resident or external wound care providers. The only interventions documented were the use of an alternating air pressure mattress and repositioning every two hours. Additionally, the facility's policy on pressure ulcers did not provide instructions on care planning or the assessment process.