Failure to Prevent and Manage Pressure Ulcers Due to Equipment Malfunction and Inadequate Nutritional Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, resulting in the development and worsening of pressure ulcers among multiple residents. Specifically, the facility did not ensure that pressure-relieving equipment, such as low air loss (LAL) mattresses, was functioning as intended. For example, one resident with severe cognitive impairment and a history of pressure ulcers developed a deep tissue injury to the thoracic spine due to a malfunctioning LAL mattress. Despite multiple work orders and staff notifications, the mattress remained unrepaired for an extended period, and there was no system in place for routine checks of air mattresses. Another resident was observed to be sunk into a malfunctioning LAL mattress with an active alarm, and the issue persisted for at least 30 minutes without resolution. The facility also failed to ensure that nutritional interventions were initiated and maintained as ordered to prevent and promote healing of pressure ulcers. Several residents with pressure ulcers or at high risk for skin breakdown did not receive timely or appropriate nutritional supplements, despite recommendations from registered dietitians. In some cases, recommendations for protein supplements or increased tube feeding rates were not communicated to or acted upon by nursing staff for weeks, and there was a lack of evidence that dietitians were notified of new or worsening wounds. Communication breakdowns between dietary, nursing, and administrative staff contributed to delays in implementing necessary interventions. Additionally, the facility did not provide adequate monitoring or documentation to demonstrate that residents were being properly assessed and interventions were being carried out as required by facility policy. For example, one resident was found to have an unstageable pressure ulcer without prior documentation of skin concerns or evidence of monitoring, and the dietitian was not notified of the wound until two weeks after its identification. The lack of interdisciplinary communication, failure to follow established protocols, and insufficient monitoring led to actual harm for several residents, including the development of new pressure ulcers and the deterioration of existing wounds.