Failure to Implement Physician's Orders for Heel Elevation
Penalty
Summary
The facility failed to implement physician's orders for a resident with diagnoses including heart failure and reduced mobility. The resident was assessed to be at risk for pressure ulcers and had limited mobility in her lower legs. On March 12, 2024, a physician ordered that the resident's heels be floated while in bed to prevent pressure ulcers. However, observations on January 14 and 15, 2025, revealed that the resident's heels were directly on the bed, contrary to the physician's orders. The resident confirmed that staff had not been floating her heels as required.
Plan Of Correction
Resident 40 heels were elevated to float heels. Current residents with orders to float heels were audited to ensure heels were elevated. DON/designee will educate nursing staff on the components of this regulation with emphasis on elevating residents' heels. DON or designee will perform an audit of 5 residents with float heels orders to ensure heels are floated. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.