Failure to Implement Ordered Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed treatments and services for pressure ulcer care and prevention for three residents identified as being at risk or already having pressure ulcers. Facility policy required residents to receive skin care, repositioning, and nutritional support to prevent avoidable pressure ulcers, and the Braden Scale was used to identify risk levels. For one resident with hemiplegia, diabetes, hypertension, and a documented Stage III pressure ulcer, the care plan and physician orders required offloading both heels while in bed, turning and repositioning every two hours, and wearing a palm guard on the left hand except during hygiene. The treatment administration record showed the palm guard was only documented as applied on two days, and multiple observations over several days found the resident lying on his back with heels not offloaded and without the palm guard in place. The resident reported that staff only sometimes assisted with heel elevation or palm guard application, and an LPN confirmed during interview that the resident’s heels were not offloaded and the palm guard was not in place. A second resident, with Parkinson’s disease, diabetes, muscle weakness, and a documented Stage IV pressure ulcer, was assessed as high risk for pressure ulcer development and required assistance to roll in bed. The care plan and physician orders directed that heel pillow boots be on when in bed, that the resident be turned and repositioned every two hours, and that a wedge cushion be used every four hours to offload the buttocks. During multiple observations on consecutive days, the resident was seen lying on her back without the wedge in place, while the wedge was observed in a chair next to the bed. When asked if staff assisted with positioning the wedge, the resident indicated negatively, and there was no indication in the report that the ordered offloading with the wedge was being implemented as prescribed. A third resident, with hemiplegia, aphasia, a history of stroke, and identified as at moderate risk for pressure ulcer development, required assistance to roll in bed. The care plan and physician orders required turning and repositioning every two hours and obtaining a wedge for offloading while in bed. Across several observations on different days, this resident was repeatedly observed in bed without a wedge in place. An LPN confirmed that the resident did not have a positioning wedge, despite the existing order. In a subsequent interview, the Nursing Home Administrator and the Director of Nursing acknowledged that the facility failed to provide the prescribed treatments and services related to pressure ulcer care and prevention for three of six residents reviewed, in violation of applicable state regulations regarding resident rights, resident care policies, and nursing services.
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