Failure to Prevent Pressure Ulcers from Developing by Nursing Home

Pruitthealth-Blythewood in Columbia, SC, has been cited after state investigators found that the facility failed to “provide appropriate pressure ulcer care and prevent new ulcers from developing.”

In this situation, a knee immobilizer was applied due to a knee fracture. The immobilizer was left in place for several weeks which caused an easily preventable pressure ulcer to form on the patient’s Achilles tendon.

Review of medical records showed that an immobilizer brace was applied because of a knee injury sustained in June. Despite having orders to remove the immobilizer brace once every shift from June and September, the brace was left in place for several weeks, against doctor’s orders.

According to nurse’s notes from June, the nursing home staff had orders to remove the immobilizer every shift to check that the resident’s skin wasn’t irritated in any way, however, there was no documentation showing that this had been done.

The Physician’s Renewals from September showed orders for staff to “place soft boot material to [the resident’s] left Achilles post dressing change to prevent friction, rubbing, and promote comfort and place underneath leg immobility brace.” However, even after a second order to do so, no documentation was found that suggested that the immobilizer had been removed, or that the resident’s skin was checked every shift as ordered.

Furthermore, the CNA Bath Report only showed documentation for one day in October, which suggests this was the only day the immobilizer had been removed and the resident had been bathed.

The facility coordinator “verified [that] staff failed to removed the immobilizer daily for general care and this caused the pressure ulcer to develop.” Had the facility’s staff followed orders to remove the brace every day for general care instead of leaving it in place for several weeks, the resident would not have developed a pressure ulcer.

In addition to failure to provide general care to prevent pressure ulcers from developing, Pruitthealth-Blythewood was also cited for:

• Failing to provide care and assistance for a resident who is unable
• One resident was left unshaven for several days, had long dirty fingernails, and was not offered assistance with brushing his teeth. Staff did not follow lift procedures during a transfer, putting this resident in danger. This resident also only had documentation for 3 showers in 3 months.
• Three residents were in need of assistance with activities of daily living (ADL) and had no documentation of weekly care.
• Failing to provide appropriate treatment and care according to orders, resident’s preferences and goals
• A resident in need of assistance was not provided positioning assistance by staff.
• Another resident was not assisted out of bed for four of five days.
• Failing to post nurse staffing information every day
• The facility did not post nursing staffing information in a way that was readily available to the public and all residents. The postings also were not complete or accurate.
• Failing to procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards
• The facility failed to prepare, distribute, and serve food under sanitary conditions, having the potential to affect all 116 residents. Kitchen staff did not wear hair restraints, kitchen equipment was not properly cleaned, and foods were not being kept at the proper temperatures until served. The facility did not have a dietary manager to make sure standards were being met.

All of these cited deficiencies put vulnerable residents at risk. It is important that nursing home staff follow orders and procedures to provide residents quality care.

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