February Featured ScenarioF-314 Proper Treatment to Prevent /Heal Pressure Sores

In this annual and extended survey the facility failed to prevent pressure sores. In this survey report it was determined that the facility failed to provide pressure relief to contracted fingers to prevent the development of an avoidable pressure ulcer for one of four residents who had pressure ulcers. Resident developed an avoidable Stage IV pressure ulcer on her right hand. Additionally, the facility failed to ensure preventive measures and thorough assessments of skin breakdown was completed which placed residents at risk for more than minimal harm that was not Immediate Jeopardy for three of four residents identified as being at risk for skin breakdown. On 04/26/10, the administrator, director of nursing, and corporate consultant were notified that Immediate Jeopardy began on 03/14/10, when Resident was found with an avoidable Stage IV pressure ulcer on her third finger of the right hand, which was described as being red, swollen with a foul odor and exposed bone. During observation of Resident's dressing change the resident exhibited visible signs of pain and discomfort. Immediate Jeopardy was removed on 04/27/10. The facility was cited at a J level.

What actions would you and your staff members take to prevent this from occurring in your facility?

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