Failure to Implement Pressure Ulcer Prevention and Wound Care Interventions
Penalty
Summary
The facility failed to implement appropriate interventions for the prevention of pressure ulcers and did not provide practitioner-ordered wound care for two residents. One resident, who was at moderate to high risk for pressure ulcer development due to limited mobility, incontinence, and cognitive impairment, experienced a decline in skin integrity. Despite worsening Braden Scale scores and the development of a stage 2 pressure ulcer and an unstageable heel ulcer, the care plan was not updated in a timely manner to reflect new interventions. Observations revealed that ordered pressure-relieving devices, such as a Roho cushion and air mattress, were not in place, and heel protectors were only implemented after the heel wound developed. Staff interviews confirmed delays in obtaining and implementing these interventions. Another resident, who had multiple comorbidities and was dependent on staff for transfers and mobility, developed an unstageable pressure ulcer on the left foot related to not wearing appropriate footwear during transfers. The care plan did not include specific interventions addressing the cause of the ulcer, such as the requirement to wear shoes during all transfers. Observations showed that staff continued to transfer the resident using a sit-to-stand lift while the resident wore only socks, and staff interviews confirmed a lack of awareness regarding the need for protective footwear during transfers. The resident also confirmed that staff had not provided instructions to change transfer practices after the ulcer was identified. Additionally, the facility failed to consistently provide and document practitioner-ordered wound care for the resident with the left foot ulcer. Review of treatment records revealed multiple missed wound care treatments on specified dates, and staff interviews confirmed that these treatments were not completed as ordered. The wound nurse acknowledged that wound care was not always documented or performed according to the physician's orders.