Failure to Implement Effective Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to implement an adequate and effective pressure ulcer prevention program for a resident who was at high risk for skin breakdown. The resident, admitted with multiple diagnoses including metabolic encephalopathy, chronic respiratory failure, COPD, and impaired mobility, was dependent on staff for most activities of daily living and was assessed as being at risk for pressure injuries. The care plan included interventions such as use of a pressure redistribution cushion, frequent turning and repositioning, incontinence care, and nutritional support. Despite these interventions being documented, observations during the survey revealed the resident was repeatedly found positioned on his back in bed during multiple checks over two days. Further review showed that the resident developed a new Stage 2 pressure ulcer to the right buttock while in the facility, in addition to an existing wound on the left buttock. Nursing staff confirmed that wound measurements were performed only twice weekly and that the resident had not been evaluated by the wound physician for the new ulcer. No additional interventions were implemented for prevention beyond those already in place, and the facility's policy required identification of at-risk residents and implementation of preventive measures. The lack of timely evaluation and absence of enhanced preventive interventions contributed to the development of the new pressure ulcer.