Failure to Implement and Document Pressure Ulcer Interventions
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including polyosteoarthritis and osteomyelitis, developed a pressure ulcer that worsened due to the facility's failure to implement and document required interventions. The resident was assessed as being at high risk for pressure injuries and had a care plan in place that included frequent repositioning, use of specialized support surfaces, and regular skin assessments. However, between mid-July and mid-August, there was no documentation of weekly skin assessments, during which time the resident developed an open area in the left gluteal fold. Despite recommendations from the wound care consultant to remove the resident's brief while in bed to relieve pressure on the wound, facility records, including Treatment Administration Records and nurse aide documentation, did not show evidence that this intervention was implemented. The wound progressed from an abrasion to an unstageable pressure ulcer, with the wound consultant repeatedly noting that pressure from the brief contributed to the worsening condition. The care plan was not updated to reflect the new wound or the consultant's recommendations, and the facility did not follow its own pressure ulcer prevention and treatment policy. Interviews with facility leadership confirmed the absence of documentation verifying implementation of the recommended interventions and weekly skin checks. The lack of timely assessment, failure to update the care plan, and non-implementation of wound care recommendations directly contributed to the deterioration of the resident's pressure ulcer.