Failure to Prevent and Timely Treat Pressure Injuries in High-Risk Resident
Penalty
Summary
A resident with multiple comorbidities, including diabetes, peripheral vascular disease, chronic kidney disease, and hemiplegia, was admitted to the facility and assessed as being at risk for pressure injuries. The resident's care plan included interventions such as daily diabetic foot checks and pressure injury prevention measures, but there was no documentation that these interventions were consistently implemented. Specifically, daily foot checks were not documented, and person-centered interventions for turning and repositioning were not included in the care plan, despite the resident being dependent on staff for activities of daily living. On one occasion, the resident's family notified facility staff of bilateral heel pressure injuries. The facility documented the left heel injury but failed to assess or document the right heel injury prior to the resident's transfer to the hospital. Upon return from the hospital, a comprehensive skin assessment was not completed until two days later, and wound care treatment orders were not implemented until four days after the resident's return. The care plan was not updated to reflect the new pressure injuries until several days after their discovery, and orders for wound care did not carry over to the Medication Administration Record (MAR) or Treatment Administration Record (TAR), resulting in a lack of evidence that wound care was provided as ordered. Interviews with facility staff revealed confusion regarding responsibility for wound care and skin assessments, with the Director of Nursing and Nursing Home Administrator unable to identify who was performing wound care rounds. Staff acknowledged that standard practices, such as comprehensive skin assessments upon readmission and timely implementation of wound care orders, were not followed. The resident was not followed by podiatry for circulatory concerns during their stay, despite recommendations in the medical record. These failures resulted in the resident developing unstageable, facility-acquired bilateral heel pressure injuries that worsened over time.