Failure to Implement Pressure Ulcer Prevention and Treatment Protocols
Penalty
Summary
The facility failed to implement its policy for pressure injury and wound management and did not ensure that treatments were completed as ordered for multiple residents with skin integrity issues. One resident, a female with dementia, Alzheimer's disease, dysphagia, peripheral vascular disease, and urinary incontinence, was identified as high risk for pressure injuries but did not receive consistent skin assessments or timely notification to the provider or responsible party when a pressure injury developed. Documentation showed missed skin assessments, delayed notification of a new pressure injury, and incomplete wound assessments. The care plan for this resident did not include specific interventions such as a turning/repositioning schedule, and interventions were not updated in response to wound deterioration. Staff interviews revealed that the resident was often left wet and not repositioned as required, with communication gaps and staffing issues contributing to missed care. Other residents with wounds or pressure injuries also did not receive wound treatments as ordered, with documentation showing missed treatments on several occasions. Staff interviews indicated that some CNAs did not follow care plans, and there were reports of staff not assisting with care, leaving residents waiting for extended periods, and not responding promptly to call lights. Cognitively intact residents reported waiting so long for assistance that they became incontinent, and observed staff ignoring call lights or engaging in personal conversations instead of providing care. Review of facility policy and nursing standards highlighted the requirement for individualized care plans, timely provider notification of wound changes, and consistent implementation of interventions based on risk assessments. The facility did not consistently document or communicate interventions, modify care plans in response to wound deterioration, or ensure that all staff were aware of and followed the required interventions. These failures resulted in residents not receiving appropriate pressure ulcer care and prevention as required by facility policy and professional standards.