Failure to Assess and Implement Interventions After Discovery of Pressure Ulcer
Penalty
Summary
The facility failed to assess and implement new interventions after an unstageable pressure ulcer was discovered on a resident's left foot. The resident, who was admitted with diagnoses including quadriplegia and polyneuropathy, was dependent on staff for bathing, dressing, and positioning, and was identified as being at risk for pressure ulcers. Despite care plan interventions such as weekly skin checks, floating heels, turning and repositioning, and use of pressure-reducing devices, a wound was found on the ball of the resident's left foot during a bed bath. Documentation indicated instructions to relieve pressure and contact the primary care provider, and the resident reported that the wheelchair footrest may have caused the wound due to lack of sensation in her legs. Observations and interviews revealed that no new interventions were implemented to alleviate pressure from the affected foot after the ulcer was found. The resident was seen in her wheelchair without a pillow under her foot, and both nursing and administrative staff confirmed that neither a therapy evaluation nor additional interventions had been initiated. There was also uncertainty among staff regarding the cause of the wound, with suggestions that either the bed bolsters or the wheelchair foot pedals could be responsible. The facility's policy required assessment and documentation of significant risk factors for pressure sores, but this was not followed after the wound was identified.