Failure to Prevent and Assess Pressure Injuries
Penalty
Summary
A resident with significant medical conditions, including Type 2 Diabetes, severe cognitive impairment, and complete dependence on staff for activities of daily living, was admitted to the facility and identified as being at risk for developing pressure injuries. The resident's care plan and facility policies required frequent turning and repositioning, use of pressure-relieving devices for both bed and chair, regular skin monitoring, and weekly skin assessments. Despite these documented interventions, the resident's physician orders did not include repositioning protocols or pressure-relieving devices, and these interventions were not consistently implemented or documented by staff. Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) failed to properly assess, document, and communicate changes in the resident's skin condition, despite repeated markings and notations of redness and open areas on the resident's posterior buttocks on shower day skin inspection sheets. The CNAs did not label their observations clearly, and the LNs did not follow up with assessments or notify the Treatment Nurse as required. Weekly Nursing Summaries, which were intended to capture changes in the resident's health status, were not completed for the month during which the pressure injuries developed. The Director of Nursing confirmed that the process for skin assessment and documentation was not followed, and that findings were not entered into the resident's chart or treatment records. As a result of these failures, the resident developed multiple pressure injuries, including an unstageable pressure injury on the sacrum, a stage III pressure injury on the left ischium, and a stage II pressure injury on the right ischium, which were discovered upon transfer to the hospital. The responsible party and family members were not informed of the presence or severity of these wounds, despite the resident's ongoing complaints of pain. The facility's lack of adherence to its own care plans and policies directly led to the development and worsening of these pressure injuries.