Petite Fleur, a Sayville, New York based nursing home, was cited by the Department of Health for multiple pressure sore violations in a recently released report. The survey, taken April 9, 2010, detailed a resident whose pressure ulcer (bedsore, decubitis ulcer) went undocumented until it had reached Stage 3. The resident had scored a “15” on the Braden Scale Assessment, indicating a risk for the development of a pressure sore.
Title 42 of the Code of Federal Regulations section 483.25(c) states that “the facility must ensure that (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.”
In this case, the resident was considered “at risk” as determined by on the Braden Assessment. Certainly this does not mean that development of a pressure ulcer is unavoidable. However, due to the risk factors present, the facility should have monitored the resident’s skin and put a plan of care in place in order to prevent the development and/or deterioration of pressure ulcers. Failure to chart an ulcer until it has reached Stage 3, at which point there is full thickness tissue loss, is unacceptable. Additionally, the resident had already developed several other pressure sores which should have made the staff more vigilant in the resident’s care and treatment.
The complete Department of Health survey can be found here.