At the time of admission, Defendant’s staff completed a pressure ulcer risk assessment, and found Plaintiff to be a “moderate risk”. As a result, skin breakdown was care planned accordingly, and interventions were developed by the staff to help prevent the development of pressure ulcers. The interventions that staff developed included checking Plaintiff for incontinence every two hours and PRN; keeping her skin clean and dry; applying a barrier cream after each incontinent episode; applying a pressure-relieving cushion to Plaintiff’s wheelchair; and checking her skin weekly. The interventions, however, were not consistently implemented by the staff. For example, staff failed to check Plaintiff for incontinence every two hours and PRN, and further failed to keep her skin clean and dry after each incontinent episode. Plaintiff’s family found her on many occasions in briefs soaked with urine, as well as urine-soaked clothes and bed sheets. Further, staff was supposed to provide Plaintiff with a wheelchair cushion to relieve pressure, pursuant to the 5/24/06 care plan. However, according to an 8/7/06 nurse’s note, Plaintiff’s family had asked staff why she still did not have the wheelchair cushion. Staff also failed to apply a barrier cream to Plaintiff after each incontinent episode. Staff purported to document applying a barrier cream to Plaintiff in the treatment sheets, and even documented applying a barrier cream to her on August 26, 2006 during the morning shift and again on the afternoon shift. However, Plaintiff was discharged from Defendant’s facility the day before. Thus, the treatment sheets purporting to document the application of a barrier cream to Plaintiff are clearly suspect. The weekly skin checks that the staff purportedly documented in the chart are also suspect. When Plaintiff suffered significant bruising to her face from a fall on 8/8/06, the bruising was not documented in the weekly skin sheets until 8/25/06—the day Plaintiff’s family took her out of Defendant’s facility.
Conspicuously absent from the staff’s 5/24/06 care plan addressing skin breakdown was an intervention for turning and repositioning Plaintiff every two hours to help prevent the development of pressure ulcers. Turning and repositioning Plaintiff every two hours was not implemented until the 7/26/06 care plan, according to the chart. But by then, Plaintiff had already developed a severe bedsore on her right buttock. The staff’s failure to turn and reposition Plaintiff every two hours was particularly egregious in this case because staff knew that she could not turn and reposition herself. According to the staff’s own documentation, Plaintiff “needed extensive assistance with bed mobility and turning and repositioning”, per an assessment dated 5/8/06 (just two days after her admission).
In summary, the staff failed to keep Plaintiff’s skin clean and dry, and instead, she was left by staff in urine-soaked clothes and bed sheets for extended periods of time; staff failed to apply a barrier cream after each incontinent episode; they failed to timely apply a pressure relieving cushion to Plaintiff’s wheelchair; they failed to turn and reposition her every two hours; and they failed to document accurate weekly skin checks. As a result of these failures, Plaintiff developed a large and painful bedsore on her right buttock.