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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Could this happen at your facility?
Share your thoughts and ideas about our monthly Challenge Scenarios (based on real life examples) with a collaborative community dedicated to improving care.
Share your thoughts and ideas about our monthly Challenge Scenarios (based on real life examples) with a collaborative community dedicated to improving care.
1. Even if the Braden Score determines low risk, there are other factors that need to be monitored to prevent chance of skin breakdown.
ReplyDeleteIndividuals with contractures and/or splint use are at high risk for skin breakdown
2. Therapy should screen residents with any MDS assessment decreases in ROM and any incidence of new wounds or decreased skin integrity.
3. Alternate interventions of treatment should be attempted and documented to avoid further issues when refusals are present.
4. Nothing in the summary or recommendations explains that the resident had a hand splint that she refused.
5. Audit tools need to be in place to assure that skin assessments/documentation are present, accurate, and being followed.
6. Review of QA process and procedures that should be identifying care areas.
7. Review of notification policies regarding new skin areas.