Failure to Monitor and Manage Pressure Ulcers
Penalty
Summary
A resident with diagnoses of dementia and Parkinson's Disease was not properly monitored or assessed for pressure ulcer risk, despite being identified as at risk for pressure injuries and requiring maximum assistance for mobility. The resident's care plan included interventions such as an air mattress, skin inspections, and heel protectors, but documentation showed inconsistencies and delays in implementing these interventions. For example, heel boots were not added to the care plan until eight days after a left heel wound was identified, and there was no documentation of offloading measures prior to the appearance of redness on the heel. Wound assessments for the resident were incomplete and lacked comprehensive details such as wound characteristics, pain, drainage, and surrounding skin condition. Several wound management reports failed to include necessary information or to document the use of pressure-relieving interventions. Additionally, weekly comprehensive wound assessments by a registered nurse were not consistently performed or documented, and the care plan was not promptly updated to reflect new or worsening wounds. Interviews with nursing staff and the DON confirmed that comprehensive wound assessments were not being reviewed to ensure wounds were not worsening and that appropriate treatments were being used. The facility's own policy required weekly head-to-toe skin inspections and comprehensive wound assessments for residents with wounds, but these procedures were not followed, resulting in delayed identification and management of pressure ulcers for the resident.