Failure to Develop Comprehensive Care Plan for Pressure Ulcer Prevention
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered care plan to address the risk of pressure ulcer development for one resident who had a history of a sacral ulcer and was identified as being at risk for pressure injuries. Upon re-admission, the resident's Braden Scale assessment indicated risk, but the care plan did not include specific interventions for pressure ulcer prevention. Staff interviews revealed that weekly skin reviews were not consistently performed according to facility policy, and preventive measures such as air mattress use, protein supplementation, frequent turning and repositioning, and off-loading of heels were not documented in the care plan prior to the development of new pressure injuries. The care plan also lacked documentation addressing the resident's refusal of care, including baths, skin assessments, and dialysis treatments. Facility policy required the interdisciplinary team to develop a care plan with measurable goals and appropriate interventions for residents at risk of pressure injuries, but this was not followed. The deficiency was confirmed through staff interviews, clinical record review, and facility documentation, with no additional information provided by facility staff during the exit meeting.