Failure to Document and Implement Pressure Injury Prevention Interventions
Penalty
Summary
The facility failed to provide consistent evidence that care plan interventions for pressure injury prevention were carried out for a resident admitted with a deep tissue injury. The resident, who had multiple diagnoses including a femur fracture, hypotension, and was receiving palliative care, had a care plan intervention requiring turning and positioning every two hours. However, documentation from the period reviewed showed only 14 notes suggesting the resident may have been moved, with just five notes specifically indicating that turning and positioning occurred. Most documentation did not clearly state that the intervention was performed as required by the care plan. Facility policies required close monitoring and documentation of pressure ulcers and chronic wounds, as well as adherence to care plan interventions for activities of daily living, including turning and positioning. Interviews with staff revealed a lack of clarity and consistency in documenting these interventions. Certified Nurse Aides reported that they were not instructed to document turning and positioning, and that communication about these interventions was informal and not reliably recorded. Attempts to demonstrate electronic documentation were unsuccessful, and staff were unable to confirm when the resident was last turned or positioned. Nursing staff, including LPNs and the Assistant Director of Nursing, confirmed that there was no systematic documentation of turning and positioning, either on paper or electronically. They expressed uncertainty about when interventions were performed and acknowledged that there was no tracking system in place. This lack of documentation and inconsistent communication among staff led to the deficiency in ensuring that the resident's care plan interventions for pressure injury prevention were consistently implemented and recorded.