Failure to Implement and Document Ordered Pressure Ulcer Interventions
Penalty
Summary
The facility failed to provide necessary treatment and services, consistent with professional standards of practice, for a resident with a pressure ulcer. Facility policy on Pressure Injury Prevention and Management required that treatment and services be provided to heal pressure injuries, that preventive interventions be implemented for all residents with pressure injuries, and that these interventions be documented in the care plan and communicated to staff. The resident, admitted with abnormal posture, paraplegia, and a right ankle pressure ulcer, had an MDS indicating a current Stage III pressure ulcer. The care plan and physician orders directed staff to encourage turning and repositioning every two hours and as needed, float heels while in bed, and apply offloading boots when in bed. However, review of the resident’s Documentation V2 Reports for February and March showed missing evidence of turning and repositioning each shift, with a total of 39 undocumented instances in February and 17 in March. During interview, the resident reported getting out of bed only once a day, needing assistance with turning and repositioning, and stated that staff turned and repositioned him maybe twice a shift. Observation found the resident lying in bed without the ordered offloading boots in place; the boots were seen in a chair, and the resident stated staff had not offered to put them on that day. An LPN confirmed the offloading boots were not on as ordered. The DON stated that for residents at risk for pressure ulcers or with wounds upon admission, interventions such as turning and repositioning, air mattress, wedges, or bunny boots are entered upon admission and are expected to be documented at least each shift, and confirmed the facility failed to document that the offloading boots were applied while the resident was in bed each shift. The Nursing Home Administrator and DON confirmed the facility failed to ensure necessary treatment and services were provided for the resident’s pressure ulcer, in violation of 28 Pa. Code 211.12(d)(5) Nursing services.
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