Failure to Prevent and Manage Pressure Ulcers Resulting in Actual Harm
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers and to ensure that a resident did not develop avoidable pressure ulcers. A resident with multiple risk factors, including dementia, a recent hip fracture, and diabetes, was admitted with a blanchable area of moisture-associated skin damage to the coccyx/buttocks and was dependent for bed mobility. Despite being identified as at moderate risk for pressure ulcers on the Braden Scale, there were no documented interventions such as turning and repositioning or heel offloading at admission, and the care plan did not include these risk reduction measures. The resident's care records showed inconsistent implementation and documentation of skin observations and heel offloading. Certified nurse aide accountability records indicated that skin checks were not signed as completed on multiple occasions, and heel offloading was not consistently performed as ordered. The resident subsequently developed a Stage 2 pressure injury on the left buttocks, which later progressed to an unstageable wound, and a deep tissue injury to the right heel. These injuries were attributed to the lack of consistent preventive interventions, such as turning, repositioning, and heel offloading, as well as inadequate monitoring and documentation by staff. Interviews with facility staff, including the DON, RNs, LPNs, and nurse practitioners, revealed gaps in communication and implementation of wound prevention protocols. Staff acknowledged that interventions like heel offloading and turning were not automatically initiated for high-risk residents and that orders and protocols were not always followed or documented. The facility's own wound management policy required comprehensive risk reduction measures, but these were not consistently applied, resulting in actual harm to the resident.