Failure to Adhere to Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to provide pressure ulcer treatment consistent with professional standards of practice for a resident identified as R106. The facility's policy on 'Pressure Ulcer Prevention' mandates the implementation of evidence-based interventions for residents at risk or with existing pressure injuries. Resident R106, admitted on January 30, 2025, had a Stage 3 pressure ulcer on the right heel. The comprehensive care plan, revised on February 4, 2025, included interventions such as offloading the heel when in bed and using heel protectors. On April 25, 2025, an observation revealed that Resident R106 was in bed without a heel boot, and the right heel was not offloaded, contrary to the care plan. A nurse aide, Employee E22, reported that the boot was stored in the resident's closet and was only applied at nighttime. The nurse unit manager, Employee E3, confirmed that the resident's right heel was not offloaded during the observation, indicating a failure to adhere to the prescribed care plan and facility policy.
Plan Of Correction
A - Resident R106 has been discharged from the facility. B - Audit of all residents with orders for pressure relieving devices to the heels to ensure device in place. C - All nursing staff educated on pressure wound prevention devices for the heels. D - Weekly x 4 then Monthly x 2 audits by DON or designee of pressure wound prevention devices for the heels to ensure compliance with interventions/orders. Results discussed during QAPI meetings.