Failure to Implement Individualized Pressure Injury Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement individualized pressure injury prevention interventions for a resident recovering from a right intertrochanteric femur fracture with decreased mobility and multiple comorbidities, including chronic combined systolic and diastolic heart failure, end stage renal disease on dialysis, muscle wasting, and gait abnormalities. The resident’s admission MDS showed he was cognitively intact, at risk for pressure ulcers, had a surgical wound, used a manual wheelchair, and had pressure-reducing devices for bed and chair. A care plan for potential skin impairment was initiated and included a general intervention to minimize pressure over bony prominences, but the clinical record lacked specific, individualized interventions to prevent or mitigate pressure injuries. Physician orders included several nutritional supplements and a skin protectant every shift, and facility policies required daily skin observation by CNAs and frequent skin inspection during bathing, hygiene, and repositioning, with use of positioning devices to offload heels as indicated. Despite these orders and policies, documentation and staff interviews showed gaps in implementation. A shower sheet documented a full body check on one date, but a subsequent shower sheet lacked documentation of a skin check. A Braden Scale assessment identified the resident as at risk for pressure injuries. A weekly skin observation later noted a small open area on the back of the right heel with treatment in place, and a facility-acquired ulceration assessment documented a deep tissue injury (DTI) to the right heel, first identified earlier in the month, described as 100% necrotic, hard, and measuring 6 cm by 6 cm with no depth. The ADON stated that the DTI was initially reported by therapy, that the resident’s surgical incision was on the same side as the DTI, and that pressure relief boots were not in place when the DTI was noticed, even though facility standards included turning and repositioning every two hours, floating heels, and offloading prominent areas. A physical therapist reported noticing the heel area while applying socks and then reporting it to the nurse, further indicating that the pressure injury was identified through therapy rather than through routine nursing skin assessments and individualized preventive measures.
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