Failure to Implement Pressure Injury Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and treatment consistent with professional standards of practice for a resident who was at high risk for skin breakdown. The resident was admitted with multiple serious medical conditions, including anoxic brain damage, acute respiratory failure with hypoxia, tracheostomy and gastrostomy status, morbid obesity, congestive heart failure, major depressive disorder, and anxiety. The resident’s MDS documented that she was comatose, had impaired upper and lower extremities bilaterally, was dependent on staff for rolling and mobility in bed, and was at risk for development of pressure injuries. The Care Area Assessment noted she was at risk for skin impairment and that preventive measures such as a pressure-reducing mattress, wheelchair cushion, and weekly skin checks were in place. Her CNA Kardex and care plan documented that she required two staff for repositioning every two hours and bilateral heel boots to offload pressure to her heels, and that she had an air mattress set to her weight for wound prevention and healing. Despite these identified risks and documented interventions, the resident developed a facility-acquired stage 3 pressure injury on the left buttock and an unstageable deep tissue injury (DTI) on the right lateral ankle. Wound physician notes described an unstageable DTI of the right lateral ankle with intact skin and purple/maroon discoloration and a stage 3 pressure wound of the left buttock with full-thickness tissue loss and granulation tissue. Subsequent wound notes continued to document the unstageable DTI on the right lateral ankle and the stage 3 pressure injury on the left buttock. The facility did not provide a pressure injury policy and procedure to surveyors, only a general “Pressure Injuries Overview” form that contained definitions and staging information but no procedural guidance. Surveyors observed multiple instances where the resident’s care plan interventions for pressure relief were not implemented. On several observations over multiple days, the resident was seen lying on her back in bed without pressure-relieving boots, with her feet either resting laterally on a pillow or directly on the mattress, and not properly offloaded. Only one observation noted a pillow under her legs to float her heels, but the pillow was flattened and both feet were still resting laterally on the pillow. The facility did not document a root cause for the development of the stage 3 left buttock pressure injury, and the resident’s care plan was not updated to include interventions addressing the potential root cause of that pressure injury. When questioned, the DON stated the facility believed the root cause was related to the incontinence product edge lying over the wound, but no additional information was provided explaining why the DTI and stage 3 pressure injury developed or why the ordered preventive interventions were not in place as observed by surveyors.
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