Failure to Implement and Document Pressure Ulcer Treatments and Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer-related treatments and to implement documented pressure ulcer prevention interventions. For one resident with multiple serious conditions including osteomyelitis, stage 4 pressure ulcers, cellulitis, lymphedema, neuropathy, and a non-pressure chronic ulcer, the physician ordered Tubigrip compression stockings with specific instructions for application and removal. Review of the Treatment Administration Record over several months showed multiple dates on which there was no documentation that the Tubigrips were applied as ordered, and additional dates with no documentation that they were removed at bedtime as ordered. An RN confirmed the lack of documentation for both the application and removal of the Tubigrips on the identified dates, despite facility policy requiring that wound treatments be documented on the TAR or in the electronic health record. The deficiency also includes failure to implement and document pressure ulcer prevention measures for another resident with multiple comorbidities such as COPD, cardiac arrhythmia, CHF, lymphedema, RA, morbid obesity, and mental health diagnoses, who required maximal assistance for mobility and self-care. The resident’s care plan called for assistance with turning and repositioning and the use of a pressure-relieving mattress. Observation showed the resident did not have a pressure-relieving mattress on the bed, and nursing staff confirmed its absence. Staff also reported that the resident was not turned and repositioned every two hours or routinely, and record review revealed multiple dates with no documentation that turning and repositioning occurred. Facility policy stated that turning and repositioning would be implemented as part of a systemic approach to pressure injury prevention and that the frequency would be documented in the plan of care.
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