Failure to Implement Physician's Order for Pressure-Relieving Devices
Penalty
Summary
A deficiency occurred when a facility failed to implement a physician's order for a resident requiring soft heel lift boots to relieve pressure on the heels. The resident, who was admitted with multiple diagnoses including atherosclerotic heart disease and had a deep tissue injury on the right heel and lateral foot, had a physician's order dated 04/14/24 to elevate heels off the bed or apply soft heel lift boots every shift. The care plan also specified the need for these interventions to protect the resident's heels. Despite these orders, observations on 04/16/25 revealed that the resident was not wearing heel boots. Interviews with nursing staff confirmed that the resident should have had at least one boot on, and that the use of wound prevention devices was crucial to prevent wound progression. The resident reported that the heel boots had disappeared and were not available. Further, staff acknowledged the importance of heel boots, especially given the resident's contractures, which made turning difficult and increased the risk of pressure on the heels. The facility's own policies required staff to review care plans for special needs and to implement physician orders promptly. However, these procedures were not followed, as evidenced by the lack of heel boots on the resident during multiple observations and staff interviews. The Director of Nursing confirmed that staff are expected to follow physician orders and that heel boots should have been applied as ordered.
Plan Of Correction
Note: This plan of correction is submitted as required by law. By submitting the plan of correction, Windsor El Camino does not admit that the citations listed on the CMS 2567 exist nor does it admit to any statements, findings, facts or conclusions that form the basis of the alleged deficiencies. This plan of correction represents our written and credible statement of compliance. We reserve the right to challenge in legal and/or regulatory or administrative proceedings the deficiencies, statements, facts, and conclusions that form the basis for the deficiencies. POC F658 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The physician's order was immediately reviewed, and soft heel boots were applied to Resident 2 as ordered. Resident 2 was assessed by nursing staff and the interdisciplinary team to ensure there were no adverse effects due to the delay in reapplying the soft heel boots. No injuries or complications were noted. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; A review of all current physician orders was conducted to ensure compliance with pressure-relief interventions. No other residents were affected by the same deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur; On 4/16/25 a 4/17/25 the DON or designee provided an in-service to Licensed Staff on the importance of timely implementation of physician orders, specifically for pressure-relieving devices. A new protocol was established requiring a second nurse to verify and document that pressure-relief devices are applied within 2 hours of the physician order. The DON or designee will audit new physician orders daily to ensure implementation within the required timeframe. How does the facility plan to monitor its performance to make sure that solutions are sustained? The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The POC is integrated into the quality assurance system; and. The DON or designee will conduct weekly audits of 3-5 random residents with physician orders for assistive or pressure-relieving devices for 4 weeks, then monthly for 2 months. Findings will be reported to the QAPI committee monthly. The committee will evaluate the effectiveness of corrective actions and adjust as necessary. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. COMPLETION DATE: 4/25/25