Failure to Escalate Pressure Ulcer Prevention After Increased Risk
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and care consistent with professional standards for one resident. The resident had severe cognitive impairment, required staff assistance for mobility and transfers, and had diagnoses including hip fracture and malnutrition. An MDS assessment documented that the resident was at risk for pressure sores but had none at that time, and the care plan identified fragile skin and the need for assistance with activities of daily living, with general interventions such as encouraging nutrition and hydration, keeping skin clean and dry, using lotion on dry skin, and monitoring/documenting skin injuries. A Braden Scale completed later showed the resident’s score had declined from 19 (low risk) to 14 (moderate risk), but the clinical record did not show that the facility identified or implemented additional interventions to address the increased pressure ulcer risk. Subsequently, progress notes documented the development of a new pressure area on the resident’s left heel, initially described as a 2 by 2 cm pressure area with black edges and a white center. Later documentation by the ARNP identified the left heel as having an unstageable pressure area with black eschar, and subsequent measurements showed the wound increasing in size to 3 by 3 cm and then 3.2 by 3 cm. Throughout this period, the record shows that the facility relied on existing care plan elements and did not document timely, risk-based preventive interventions in response to the declining Braden score. The DON reported not knowing when interventions to prevent pressure ulcers were started and stated that they did not really have a procedure to prevent or treat pressure ulcers until recently. The NPIAP guidance cited in the report emphasizes structured risk assessment and development of a plan of care based on identified risk areas, including repositioning and ensuring heels are free from pressure, which contrasts with the lack of documented, timely preventive measures in this case.
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