Failure to Prevent Pressure Ulcers Due to Inadequate Assessment and Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to prevent the development of pressure ulcers in a resident who was at high risk due to severe cognitive impairment, hemiparesis, and dependence on staff for mobility and activities of daily living (ADLs). The resident was admitted without any skin breakdown and was identified as being at risk for pressure ulcers through the Braden Scale and Minimum Data Set assessments. Despite this, the care plan did not include specific interventions such as regular turning and repositioning, use of offloading devices, or strategies to address the resident's tendency to reposition himself onto the affected side. The care plan also lacked updates after the resident began exhibiting behaviors that increased his risk, such as removing pillows used for offloading pressure. The facility's staff did not consistently monitor or document the resident's skin condition as required by policy. There were multiple instances of missing documentation in the ADL Skin Observation Logs across all shifts, and shower sheets were not filed in the resident's chart. Staff interviews confirmed that if documentation was missing, it meant the skin was not checked, which could delay the identification of new or worsening wounds. The facility's policy required CNAs to inspect skin during ADL care and for licensed nurses to document the effectiveness of pressure ulcer prevention techniques, but these steps were not reliably followed. As a result of these failures, the resident developed multiple pressure-related injuries, including dark purple discolorations on the heel and foot, deep tissue pressure injuries, and a Stage III pressure ulcer on the hip. The interdisciplinary team did not convene as required to address the resident's skin breakdowns or revise the care plan to include more effective interventions. The lack of timely assessment, documentation, and care plan updates directly contributed to the resident's skin breakdown and the progression of pressure injuries.