Failure to Implement Comprehensive Pressure Ulcer Management Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement key components of a comprehensive pressure ulcer management plan for a resident admitted with a stage 4 sacral pressure ulcer, dementia, and dysphagia. The resident required total assistance with bed mobility and was to be turned and repositioned in bed as necessary, but during an observation period of over two hours, staff were seen entering the room for perineal care, linen removal, blood sugar checks, and wound care without evidence of repositioning to offload the sacral wound. The resident’s niece reported that the resident had not been positioned to offload the wound during that shift and stated that the Wound Care Coordinator (WCC) had told her manual turning was unnecessary due to the alternating-pressure mattress. The WCC confirmed that belief, stating that residents on alternating-pressure mattresses do not require manual turning every two hours and that the mattress takes the place of manual turning, repositioning, and offloading, despite the facility Kardex indicating the need for turning and repositioning. The facility also failed to ensure proper use and monitoring of the resident’s specialty mattress and nutritional supplement ordered to support wound healing. The alternating-pressure mattress was observed on three consecutive days to be set for a 160 lb person, while the resident’s most recent documented weight was 125.6 lbs, even though the physician order required staff to check and ensure mattress settings matched the resident’s weight each shift. The mattress manufacturer’s manual specified that the system is intended for prevention and treatment of pressure ulcers when used with a comprehensive pressure ulcer management program and did not state that it replaces offloading, manual turning, or repositioning. Additionally, the resident’s physician orders included an arginine powder nutritional supplement three times daily since admission, but electronic medication records showed 75 missed doses documented as not available or awaiting pharmacy delivery. A prior wound assessment by the wound physician documented deterioration of the lower back wound, including new undermining, watery drainage, pale granulation tissue, and less organized wound base, and emphasized the imperative need for continued offloading and supervision of high-protein nutrition.
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