Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, left femur fracture, and malnutrition was admitted to the facility without any pressure ulcers and was assessed as being at risk for developing them. The resident was dependent on staff for all transfers, bed mobility, dressing, and toilet hygiene, and had an indwelling urinary catheter with frequent bowel incontinence. Despite being identified as at risk, the care plan did not address the development of a Stage 3 pressure ulcer that was identified on the resident's sacrum. Physician orders were issued for wound treatments, an air mattress, and repositioning every two hours, but these interventions were not consistently implemented. Observations revealed multiple failures in following physician orders and standard care practices. The resident was found without a dressing on the pressure ulcer, and infection control techniques were not utilized during wound care. The air mattress, which was ordered to reduce pressure, was not in place on several occasions. Staff omitted key components of the wound care treatment, such as the application of calcium alginate, and failed to perform hand hygiene or change gloves during wound care. The resident was also left in a wheelchair for extended periods without repositioning or toileting assistance, and staff were unaware of the resident's skin impairments. Further observations documented that the resident's sacral wound was left without a dressing, and a new open area developed on the coccyx. The air mattress intervention continued to be unimplemented, and the resident was found with incontinent stool on the buttocks. Nursing staff admitted to being behind on treatments and not completing wound care as ordered. The care plan and Braden scale assessments were not updated to reflect the resident's changing condition, and the facility failed to ensure timely and appropriate interventions to prevent further skin breakdown.