Failure to Plan, Document, and Obtain Physician Assessment for Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for a resident admitted with bilateral heel pressure wounds and multiple risk factors, including Alzheimer’s disease, moderate protein-calorie malnutrition, immobility, incontinence, and severe cognitive impairment. On admission, the resident required total assistance with all ADLs and was identified through a tissue tolerance assessment as needing repositioning more often than every two hours. A skin condition assessment documented a right heel pressure ulcer and listed ongoing interventions such as a pressure relief device in the chair, turning and repositioning program, nutrition and hydration interventions, and dressing changes, and directed staff to initiate a care plan. Despite these identified needs and risk factors, the care plan initiated later in December did not include pressure ulcer prevention measures such as a turning and repositioning program, use of positioning devices (e.g., wedges or pillows), a repositioning schedule, or off-loading of the heels while in bed. The nutrition care plan did not outline strategies for feeding the resident or actions to take when the resident refused to eat, even though staff reported the resident often refused to open his mouth at meals. CNAs reported the resident was tall, thin, underweight, did not get out of bed, and required two-person assistance for repositioning due to yelling and swinging at staff, yet there was no documented repositioning schedule or plan to address these needs. Skin monitoring and wound management were also deficient. Daily shower skin check sheets on multiple dates were incomplete or lacked documentation of whether the skin was intact, and when bruises and a rash were noted, no locations or follow-up interventions were documented. On one date in late December, an RN documented new sacral pressure ulcers with reddened skin and two open circular areas on both sides of the sacrum, cleansed the wounds, and applied ointment and foam dressing. However, after these new sacral wounds were identified, there was no documentation that the wound NP or physician/physician extender assessed the sacral wounds from that date through discharge. The DON acknowledged that residents with pressure wounds or at risk should have care plans for prevention and healing and be repositioned every two hours, but was unable to provide documentation that this resident was repositioned as expected or that a plan was in place to meet the resident’s repositioning needs prior to the development of the sacral pressure ulcers.
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