Failure to Ensure Consistent Use of Pressure-Relieving Devices
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure ulcers. This deficiency was identified during a recertification survey, where it was observed that a resident, who was at risk for pressure ulcers, was not consistently wearing a prescribed pressure-relieving device, known as a bunny boot, on both feet as ordered by the physician. The resident had a history of venous insufficiency, wound infection, and malnutrition, and was cognitively intact but required assistance for lower body dressing. Despite the physician's order to apply bunny boots to both heels while in bed, the resident was repeatedly observed with only one boot on, and there were instances where the right boot was missing or not applied. The facility's policy on the prevention and treatment of pressure ulcers emphasized the importance of protecting skin against pressure and ensuring proper use of assistive devices. However, documentation and interviews revealed lapses in adherence to this policy. Certified Nursing Assistants and Registered Nurses acknowledged the resident's non-compliance and the missing device, but there was a lack of consistent documentation and follow-up. The Director of Nursing confirmed that assistive devices had not been discussed in Quality Assurance Performance Improvement meetings, indicating a gap in oversight and accountability for ensuring the resident's prescribed care was followed.
Plan Of Correction
Plan of Correction: Approved February 27, 2025 This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1) Immediate actions taken for those residents identified: Resident # 11 was examined immediately. No harm was noted. Care Plan was reviewed and kept the same. Resident has a MD order for two bunny boots, reviewed and kept the same. MD orders for bunny boots reflected in Potential for Skin Breakdown Care Plan. Resident was provided with additional bunny boot for right lower extremity. Nurses on unit received one-on-one in-service for Assistive Devices placement and Pressure Ulcers Prevention. 2) How the facility identified other residents: All residents potentially can be affected by deficient practice. The Director of Nursing audited all residents with assistive devices for assistive devices placement. No other residents were affected. 3) Measures put into place/System changes: Policy of Pressure Ulcers Prevention were reviewed and kept the same. All nursing staff were re-in-serviced on proper placement of assistive devices and signing eTAR accordingly as per Assistive Devices placement and Pressure Ulcers Prevention Policy on 02/17/2025. 4) How the corrective actions will be monitored: An Audit tool was developed on monitoring compliance with placement of assistive devices. All nursing staff in-serviced on proper placement of assistive devices. Each shift medication nurse shall check placement and sign the eTAR. Director of Nursing is responsible to submit results of Quality Assurance Audit to Administrator on a weekly basis for a year and presented to QAPI meeting for the next two quarters until compliance is achieved. The Director of Nursing is responsible for the implementation and monitoring of the plan.