Failure to Prevent and Timely Identify Pressure Ulcers in At-Risk Resident
Penalty
Summary
Facility staff failed to implement necessary interventions, care, and services to prevent the development of pressure ulcers in a resident identified as being at risk. The resident, who had multiple comorbidities including end stage renal disease, diabetes, heart failure, dementia, and a history of sacral pressure ulcers, was re-admitted to the facility with intact skin. Despite being at risk, as indicated by a Braden Scale score of 17 and a history of previous pressure injuries, the resident did not have a care plan addressing pressure ulcer prevention, and no specific interventions were documented to prevent pressure-related injuries. Weekly skin assessments, as required by facility policy, were not consistently performed between the resident's re-admission and the discovery of two advanced-stage pressure injuries. The facility only identified the injuries during a facility-wide skin sweep, which was initiated after it was recognized that weekly skin reviews were not being completed. Documentation also showed inconsistent or missing records for turning and repositioning, which are critical interventions for pressure ulcer prevention, especially for residents with limited mobility and incontinence. Interviews with facility staff, including the Wound Care Nurse and DON, confirmed that preventive measures such as air mattresses and regular repositioning were only implemented after the wounds were discovered, rather than proactively based on the resident's risk profile. The care plan lacked interventions for pressure ulcer prevention and did not address the resident's refusal of care or changes in condition. Facility policies required systematic risk assessment, care planning, and intervention for at-risk residents, but these were not followed, resulting in the resident developing two advanced pressure injuries.